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MEDICAL DISEASES 



OF 



INFANCY AND CHILDHOOD 



BY 



DAWSON WILLIAMS, M.D. Lond. 

FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS OF LONDON, AND OF4UNIVERSITY COLLEGE, 
LONDON ; PHYSICIAN TO THE EAST LONDON HOSPITAL FOR CHILDREN, SHADWELL 



SECOND EDITION REVISED WITH ADDITIONS 



BY 

FRANK SPOONEE CHURCHILL, M.D. 

INSTRUCTOR IN DISEASES OF CHILDREN, RUSH MEDICAL COLLEGE, IN AFFILIATION WITH THE 
UNIVERSITY OF CHICAGO ; PROFESSOR OF PEDIATRICS, CHICAGO POLYCLINIC 



ILLUSTRATED WITH 72 ENGRAVINGS AND 2 COLORED PLATES 




LEA BROTHERS & CO. 

PHILADELPHIA AND NEW YOEK 
1900 



40348 



Llbmry at Cong 

'' «u Cuncs Rccciifco 
AUG 30 1900 

Auny-Wtrisoo 

Stcow COPY. 

IMMnill* 

OROeX DIVISION, 
SEP 11 1900 



^? 






69715 

Entered according to the Act of Congress in the year 1900, by 

LEA BKOTHEES & CO. 
In the Office of the Librarian of Congress. All rights reserved. 



PREFACE TO THE AMERICAN EDITION. 



It has been the object of the reviser, iu preparing this book of 
Dr. AVilliams' for its second American issue, to adapt it more closely 
to the special requirements of this country. 

The original text is here presented entire, no part having been 
omitted. The additions, requisite to bring the work up to date and 
to represent American views, have been enclosed in brackets. The 
prescriptions have been scattered through the text for convenience 
of connected reading. They have been conformed to the United 
States Pharmacopeia. The reviser however would not imply that 
a specific prescription refers to a specific instance. To avoid the 
possibility of misinterpretation the Appendix of Prescriptions as a 
whole is retained as in the original edition. 

Particular attention has been given to infant-feeding, both on 
account of its importance and because in this respect the original 
edition seems to depart most from American ideas and standards. 

The reviser wishes to acknowledge his indebtedness to the various 
authors consulted, especially to Dr. T. M. Rotch. He wishes par- 
ticularly to express to Dr. Williams the interest and profit found in 
the study of his work, and trusts that the additions made may be of 
value to the public. - 

F. S. C. 
Chicago, III., August, 1900. 



PREFACE TO THE ENGLISH EDITION. 



The object of this handbook is to give to young practitioners of 
medicine, and to those who have not previously paid much attention 
to the subject, a guide to the clinical study of disease as it occurs in 
infancy and childhood. 

Xo attempt has been made — nor was it, indeed, possible within 
the space at my disposal — to attain an ideal completeness in the 
enumeration of all the forms of disease wliich may occasionally be 
met with in infants and children. Pathological processes are essen- 
tially the same in children as in adults. The differences to be ob- 
served are traceable in the main to two causes. In the first place, 
the organism in childhood is growing, and while it is peculiarly 
\'ulnerable to external agencies, it possesses also a special power of 
adaptation and recuperation. In the second place, the organism in 
childhood has not yet acquired immunity to the acute specific 
infectious diseases which are, as a matter of fact, responsible for a 
very large part of the enormous mortality of the early years of life. 

I have not deemed it to be my dut^' to attempt to describe fully 
diseases which present symptoms similar at all ages. My object has 
been rather to indicatis the special incidence of disease in childhood ; 
to elucidate as far as possible the causes of this special incidence ; to 
point out the peculiarities which the circumstances of child-life im- 
press upon familiar diseases ; and to detail the treatment rendered 
appropriate by the nature of the disease itself and by the peculiar 
susceptibility of the growing organism. While it would be difficult 
to mention any disease — except, perhaps, rickets — which is peculiar 
to childhood, yet certain morbid processes present special features or 
a peculiar distribution in childhood, and others, common at that 
period, are rare in adult age. Moreover, the relative importance of 
diseases varies greatly at different ages. Diarrhoea, for instance, 
which at adult ages and in temperate climates is usually a trivial, 



6 PREFACE. 

seldora a fatal, affection, is in infancy and early childhood the most 
deadly of all disorders. 

In discnssing the subject of treatment, prominence has been given 
to the rational basis afforded by pathology, and by clinical observa- 
tion. While it is hoped that few remedies which experience has 
proved to be valuable have been omitted, it has not been thought 
worth while to compile long lists of drugs which have been recom- 
mended and employed without a reasonable measure of success. I 
have been guided throughout, both in clinical description and in the 
treatment recommended, by experience gained during many years' 
service at the East London Hospital for Children, Shadwell. The 
opportunities for observation there afforded are very extensive, but 
they have failed me in regard to two forms of disease. Malaria is 
seldom seen in London in children, but I have been so fortunate as 
to obtain the assistance of Dr. Manson, who has been good enough 
to revise the chapter on Malarial Fever. Hydatid disease also is 
extremely rare in this country, and I am greatly indebted to my 
friend, Mr. G. Twynam, formerly Surgeon to the Prince Alfred 
Hospital, Sydney, New South Wales, who has read the chapter on 
this subject, and has made many valuable suggestions which are em- 
bodied in the text. In conclusion, I must express my acknowledg- 
ments to Miss Mary Gordon, L.R.C.P. & S. Ed., who has read the 
proofs, and assisted me in seeing the volume through the press. 



CONTENTS. 



CHAPTER I. 
INTRODUCTORY. 

PAGE. 

The Ages of Childhood— Growth— The Mortality of Childhood— Its Causes- 
Influence of Sex — Sleep — Clothing — Baths — Change of Air 17 

CHAPTER II. 

CLINICAL EXAMINATION. 

Clinical Examination of Infants and Young Children — General Observations — 
Physical Examination of the L'pper Air Passages — Of the Chest — Of the 
Circulatory System — Of the Abdomen — Of the Head — Retraction of the 
Head — The Temperature in Infancy and Early Childhood 



o: 



CHAPTER III. 
DISEASES INCIDENTAL TO BIRTH 

Hjemorrhagic Extravasations during Parturition ; Meningeal Hemorrhage — 
Icterus Neonatorum — Acute Fatty Degeneration of the New-Born— Acute 
Haemoglobinuria of the New-Bom — Mastitis — Erysipelas Neonatorum — 
Erythema Neonatorum — Diseases of the Navel — Tetanus Neonatorum — 
Sclerema Neonatorum — (Edema Neonatorum — Melfena Neonatorum — Pem- 
phigus Neonatorum — [Haemorrhagic Diseases of the Nevr-Born] 36 

CHAPTER lY. 

FOOD. 

The Stomach and Intestines at Birth — Milk — Physiolog}' of Digestion — The 
Quantity of Milk taken at Various Ages — Rate of Increase in "Weight — 
[Management of Breast Feeding] — Artificial Feeding of Infants — Fresh 
Cow's Milk— Condensed Milk— Infants' Foods— The Bottle— Efl'ects of 
Boiling — Bacteriology of Milk — Sterilization — Pasteurization — Milk Labo- 
ratories — [Modification of Cow's Milk — Indications for Modifying — Diet in 
Second Year] 52 



8 CONTENTS. 

CHAPTER V. 

ACUTE SPECIFIC INFECTIOUS DISEASES: INTKODUCTORY. 

Mortality due to the Acute Specific Infectious Diseases — Incubation Period — 
Propliylaxis— Complications and Sequelae — General Remarks on Treatment : 
Nui-sing, Food, Drink, Alcohol — Hydrotherapeutic Treatment — Antipyretic 
Drugs — Treatment of Adynamia 83 

CHAPTEK yi. 

ACUTE SPECIFIC INFECTIOUS DISEASES {continued). 

Small-pox — Vaccination — Symptoms and Treatment of Small-pox — Varicella — 

Measles — Rubella — Scarlet Fever 94| 

CHAPTER VII. 

ACUTE SPECIFIC INFECTIOUS DISEASES {continued). 

Influenza — Whooping-cough — Mumps — Glandular Fever — Cerebro-spinal Men- 
ingitis — Enteric Fever 112 

CHAPTER YIII. 

ACUTE SPECIFIC INFECTIOUS DISEASES {concluded). 

Diphtheria — Incubation Period — Pathology — Symptoms — Diphtherial Palsy — 
Diagnosis — Prognosis — Antitoxin Treatment — General and Local Treat- 
ment — [Immunization] 132 

CHAPTER IX. 

MALARIAL FEVER. 

The Hfematozoon — Varieties of Malarial Fever : Quotidian ; ^stivo-autumnal ; 

Pernicious — Malarial Cachexia — Diagnosis — Prognosis — Treatment 152 

CHAPTER X. 

TUBERCULOSIS: ETIOLOGY; PATHOLOGY. 

The Tubercle Bacillus— The Tuberculous Diathesis— Sources of Infection- 
Milk— Predisposing Diseases— Sites of Primary Infection : Naso-Pharynx 
and Cervical Glands ; Ear ; Intestines— Varieties of the Tuberculous Proc- 
ess—Age Incidence— Prevalence of Tuberculosis in Childhood— Sex 156 

CHAPTER XL 

CLINICAL VARIETIES OF TUBERCULOSIS. 

Tuberculosis and Scrofula— General Tuberculosis : Acute and Chronic— Tuber- 
culosis of Bones and Joints— Tuberculosis of Lymphatic Glands ; the Cervi- 
cal and Tracheo-bronchial Glands 163 



CONTENTS. B 

CHAPTER XII. 

TUBERCULOSIS OF THE ABDOMINAL ORGANS. 
Tuberculosis of the Mesenteric Glands — Tuberculosis of the Peritoneum : Acute, 

Chronic — Stomach — Spleen — Liver 173 

CHAPTER XIII. 

PULMONARY TUBERCULOSIS. 
Acute Pulmonary Tuberculosis — Acute Tuberculous Pneumonia — Acute Tuber- 
culous Broncho-pneumonia — Chronic Pulmonary Phthisis — [Tuberculin] — 
General Remarks on Treatment 183 

CHAPTER XIV. 
SYPHILIS. 
Inherited Syphilis ; Infection ; Symptoms ; Lesions of Skin and Mucous Mem- 
branes, of Viscera, of Bones ; Contagiousness — Late S^-jihilis — Diagnosis of 
Inherited S^-philis — Prognosis — Acquired Syphilis — Treatment of Syphilis.. 191 

CHAPTER XV. 

RHEUMATIC FEVER. 

Etiology — Symptoms — Endocarditis and Pericarditis — Subcutaneous Nodules — 

Rashes — Diagnosis — Prognosis — Cervical Rheumatism — Treatment 208 

CHAPTER XVI. 

CHRONIC RHEUMATIC AFFECTIONS. 
The Rheumatic Cachexia, and Chronic Rheumatism — Rheumatoid Arthritis 218 

CHAPTER XVII. 

INFECTIVE ARTHRITIS. 
Polyarthritis and Monarthritis — Scarlet Fever — Diphtheria^Typhpid Fever — 
Mumps — Gonorrhoea — Acute Epiphysitis — Prophylaxis and Treatment of 
Infective Arthritis 221 

CHAPTER XVIII. 
CHOREA. 
General Characters — Etiolog}^ — Pathology — Symptoms — Recurrence — Treat- 



ment. 



225 



CHAPTER XIX. 

I RICKETS. 

Etiology — Pathology — Symptoms — Bony Deformities — Late Rickets — Compli- 
cations — [Early Diagnosis] — Treatment 232 



10 CONTENTS. 

CHAPTER XX. 

SCURVY. 

Age — Etiology — Morbid Anatomy — Symptoms— Course — Treatment 243 

CHAPTER XXI. 
ANEMIA AND LEUCHJEMIA— HEMOPHILIA. 
[Normal Blood in Early Life] — Secondary Anaemia — Primary Anaemia — Chlo- M j 
ro^^is — Progressive Pernicious Anaemia — Splenic Anaemia — Leucliaemia — T 
Hodgkin's disease — Haemophilia 247 

CHAPTER XXII. 

DISEASES OF THE THYROID AND THYMUS GLANDS. 
Acute Thyroiditis— Goitre— Cretinism— The Thymus Gland ; Anatomy ; Thy- 
mic Asthma 255 



CHAPTER XXIII. 

DISEASES OF THE HEART. 



ar- ■ 



[Normal Position of the Heart] — Congenital Affections of the Heart — Pericar- 
ditis — Pleuro-pericarditis — Acute Endocarditis ; Simple ; Malignant — 
Chronic Endocarditis — Valvular Disease 270 



CHAPTER XXIV. 

DISEASES OF THE MOUTH. 

The Mouth — Dentition — Disorders of Dentition — Stomatitis — Partial Des- 
quamation — Catarrhal Stomatitis — Membranous Stomatitis — Ulcerative 
Stomatitis — Aphthous Stomatitis — Thrush — Noma 285 

CHAPTER XXV. 

DISEASES OF THE UPPER RESPIRATORY PASSAGES. 

Rhinitis — Acute Laryngitis — Chronic Laryngeal Catarrh — Papilloma of the 
Larynx — Acute Pharyngitis — Acute Tonsillitis — Otitis Media — Chronic 
Pharyngitis — Adenoid Vegetations — Chronic Tonsillitis — Deformities of 
the Chest produced by Naso-Pharyngeal Obstructions — Retro-Pharyngeal 
Abscess — Respiratory Spasm 297 

CHAPTER XXVI. 

ACUTE BRONCHITIS, BRONCHO-PNEUMONIA, AND PNEUMONIA. 

Acute Bronchitis and Broncho-pneumonia : Pathology ; Symptoms ; Prog- 
nosis ; Treatment — Acute Lobar Pneumonia : Etiology ; Pathology ; 
Symptoms ; Complications ; Diagnosis ; Treatment 314 



CONTENTS. 11 

CHAPTER XXVII. 

PLEURISY. 

Sero-fibrinous Effusion — Purulent Effusion — Symptoms of Pleurisy — Course — 

Physical Signs — Loculated Empyema — Treatment 332 

CHAPTER XXYIII. 

CHRONIC AFFECTIONS OF THE BRONCHI. 
Chronic Bronchitis and Emphysema — Bronchiectasis — Asthma — "Hay 
Fever" ' 340 

CHAPTER XXIX. 

PERITONITIS. 
Acute Peritonitis — Chronic Peritonitis — Appendicular Peritonitis ; Local Ad- 
hesive Peritonitis ; Peri typhlitic Abscess ; Acute General Peritonitis 347 

CHAPTER XXX. 

DISEASES OF THE LIVER. 

Jaundice — Catarrhal Jaundice — Infective Jaundice — Acute Yellow Atrophy — 
Cirrhosis — Amyloid Degeneration — Fatty Infiltration — Fatty Degeneration 
— Suppurative Hepatitis '. 356 

CHAPTER XXXI. 

ACUTE DISORDERS OF THE GASTRO-INTESTINAL SYSTEM. 

Etiology — Dyspepsia — Catarrhal Enteritis — Gastro-intestinal Catarrh — Acute 
Gastro-enteritis — Acute Summer Diarrhoea — [Bacteriology] — Cholera In- 
fantum — Complications — Treatment 365 

CHAPTER XXXII. 

CHRONIC DISORDERS OF THE GASTRO-INTESTINAL SYSTEM. 
Chronic Gastro-enteritis — Dilatation of the Stomach — Infantile Atrophy — The 
Hydrocephaloid Condition — Congenital Stenosis of the Pylorus — Constipa- 
tion — Prolapsus Ani 383 

CHAPTER XXXIIL 

INTESTINAL OBSTRUCTION. 
Congenital^ Acquired — Symptoms — Diagnosis — Treatment 395 

CHAPTER XXXIV. 

INTESTINAL PARASITES. 
Tsnia Solium — Taenia Mediocanellata — Bothriocephalus Latus — Tsenia Canina ; 
Symptoms of Tape-worm ; Prophylaxis ; Treatment — Ascaris Lurabri- 
coides ; Treatment — Oxyuris Vermicularis ; Treatment 399 



12 CONTENTS. 

CHAPTEK XXXV. 

HYDATID DISEASE. 
Taenia Echinococcus — Geographical Distribution — Hydatid of the Liver ; of 

the Lung ; of the Heart ; Intracranial : of the Kidney and Spleen 406 

CHAPTER XXXVI. 

DISEASES OF THE GENITO-URINARY SYSTEM. 

The Urine — Albuminuria — Albuminuria of Puberty — Haematuria — Hsemoglo- 
binuria — ^Pyuria — Diseases of the Kidney : Diffuse jS^ephritis ; Glomerulo- 
Nephritis ; Amyloid Degeneration ; Uric Acid Diathesis ; Renal Calculus ; 
Hydronephrosis ; Pyelitis ; Perinephritic Abscess ; Congenital Cystic Dis- 
ease of the Kidneys ; Tumors of the Kidney 411 

CHAPTER XXXVII. 

DISEASES OF THE NERVOUS SYSTEM. 
The Nervous System in Infancy — Night Terrors — Headache — Stammering and 
Stuttering — Alalia — Deaf -Mutism ; Forms ; Causes ; Prophylaxis ; Treat- 
ment 432 

CHAPTER XXXVIII. 

HYSTERIA: PICA. 
Hysteria : Definition ; Somnambulism ; Delirium ; Paralysis ; Neuro-mimesis ; 

Fasting Girls — Diagnosis of Hysteria — Treatment — Pica or Dirt Eating 440 

CHAPTER XXXIX. 

TETANY AND LOCAL SPASMS. 
Tetany ; Etiology ; Symptoms ; Prognosis ; Diagnosis ; Treatment — Local 

Spasms; Eyes; Head and Trunk ; Treatment — Habit Spasms 444 

CHAPTER XL. 
ECLAMPSIA AND EPILEPSY. 

Infantile Convulsions : Causes ; Symptoms ; Treatment — Epilepsy : Etiology ; 
Symptoms ; Jacksonian Epilepsy — Diagnosis of Epilepsy and Eclampsia — 
Prognosis and Treatment of Epilepsy 451 

CHAPTER XLI. 

MENINGITIS. 

General Etiology and Symptoms : Intracranial Tubercle ; Tuberculous Menin- 
gitis — Anatomy — Etiology — Symptoms — The Diagnosis of Meningitis — 
Treatment — Posterior Basal Meningitis — Hydrocephalus 459 



II 



CONTENTS. 13 

CHAPTER XLII. 

INTEACKANIAL ABSCESS, THROMBOSIS, AND TUMOUR. 

Abscess of the Brain ; Course ; Diagnosis ; Treatment — Thrombosis of Cerebral 

Sinuses — Intracranial tumour 473 

CHAPTER XLIII. 

HEMIPLEGIA. SPASTIC RIGIDITY. HEREDITARY ATAXY. - 
Secondary Hemiplegia — Congenital and infantile Hemiplegia — Spastic Rigidity 
- -Hereditary Ataxy 481 

CHAPTER XLIY. 

LESIONS OF NERVES. 

The Motor Nervous Apparatus — Reaction of Degeneration — Birth Palsies — 

Facial Paralysis — Multiple Neuritis 489 

CHAPTER XLV. 

AMYOTROPHY. 
Muscular Atrophy — Infantile Paralysis — Progressive Neural Muscular Atrophy 
— Primary Muscular Dystrophies — Pseudo-h'ypertrophic Muscular Paraly- 
sis 494 

CHAPTER XLYI. 

DISEASES OF THE SKIN. 
Urticaria — Urticaria Papulosa — Raynaud's Disease — Prurigo — Urticaria Pig- 
mentosa — Er}*thema Simplex — Erythema Intertrigo — Erythema Scarlatini- 
forme — Erythema Multiforme — Purpura — Peliosis Rheumatica — Chilblain 
— Pemphigus — Herpes — Pruritus — Itching; Pediculosis; Scabies.. 504 

CHAPTER XLVII. 

DISEASES OF THE SKIN {cmtinued). 
Pyococcal Dermatitis — Impetigo — Catarrhal Dermatitis — Furuncle — Ringworm 

— Alopecia Areata — Seborrhoea — Lichen — Miliaria — Eczema and Psoriasis. 517 

Appendix 526 



MEDICAL DISEASES 

OF 

Infancy and Childhood. 



CHAPTER I. 
IXTEODUCTORY. 



The Ages of Childhood — Growth — The Mortality of Childhood — Its Causes — Influ- 
ence of Sex — Sleep — Clothing — Baths — Change of Air. 

The Ages of Childhood. — Within the period of childhood are 
included two of the ages of man — infancy and childhood proper. 

Tiifanci/ is used often in a loose sense to signify the period of early 
childhood. Etymologically the word " infant '' signifies a child 
which has not yet acquired the art of speech.^ It was extended by 
the Romans themselves to include children up to the age of seven 
years. For medical purposes it is better to define infancy as the 
period during which the child suckles, since this is a well-defined 
epoch of life which comes to a natural termination with the establish- 
ment of the first dentition. It corresponds with the Sduglinc/sff/fcrSy 
or suckling age, of German writers, and may be held to extend in 
the healthy child to the end of the first year, at which age, or soon 
after, the first molars are cut. It is convenient to recognize as a 
separate age or period of life the first two or three weeks, during 
which the organism of the new-born infant undergoes important 
adaptations to the new conditions of independent existence. 

Childhood proper extends from infancy to puberty. It embraces 
the whole period of the functional activity of the first set of teeth, 
and the establishment, though not the completion, of the second 
dentition. In Rome the boy assumed the fof/o viri/is at the age of 
fourteen or fifteen. In more northern countries puberty develops a 
little later, but in both sexes there are very considerable individual 
variations. Menstruation may begin as early as the tenth year — in 

^ /u, not ; fans, present participle of /an, to speak. (Skeat. ) 
2 17 



18 



INTRODUCTORY. 



\\\vv cases even earlier — or may be postponed to the seventeenth, or 
even later. 

Growth. — During the first few days after birth there is a slight 
decrease in weight, which is not regained until about the end of the 
second week. After this, in a healthy infant, the increase in weight 
is steadv ; but the rate of increase dechnes progressively. At the 
end of the fifth month the weight will be about twice that at birth, 
but it will not reach thrice the weight at birth until the child is a 
year old. After weaning, if the child is wisely fed, and remains in 
good health, the weight at the end of the second year will be about 
four times that at birth. If we take the average weight of an infant 
at birth to be TJ lbs. (3,000 grammes; male 3,200, female 2,900) ^ 
we shall, by calculation, obtain the following weights : — At five 
months 15 lbs. (6,000 grammes); at one year 221 lbs. (9,000 
grammes) ; figures which agree very closely with the averages 



3,000 



obtained by Sutils ^ from actual Aveighings : — At birth 
grammes ; at five months 6,250 grammes ; at twelve months 9,000 
grammes; at twenty-four months 11,550 grammes. 

[The average weight at one year, given above, is higher than that 
observed by most American authors, who place it at about 20 lbs. 
This average, however, is based on statistics taken from hospital 
children ; observations made in private practice will range somewhat 
higher on account of the better care and feeding of the latter class of 
children. The value of weekly observations on the weight of infants 
during the first year cannot be overestimated. The healthy infant 
should gain, at least, four ounces weekly during the first six months; 
in the second six months it may be slightly less. If the infant be 
weighed more than once a week, we must be prepared to see marked 
variations in the rate of gain, e. g., a gain of .5-1 ounce the first 2-3 
days of the week, and of 3-5 ounces the last 3-4 days, and vice 
versa. 

Except in special cases, therefore, it is wiser to weigh but once a 
week, especially if we have to do with an infant at the breast of a 
nervous mother, whose milk may be upset by too critical an analysis 
of the weight-curve. 

The following chart (Fig. 1), by Griffith, is of practical conve- 
nience in recording the infant's weight.] 

The increase in height is also regular, and follows a similar law — 
that is, the rate is rapid at first, and gradually declines. This has 
been expressed conveniently by Liharzik, who found that on the 
average an increase in height of 7J centimetres (3J inches) took 
place in periods progressively longer as the infant became older ; 
thus this increase took place in succeeding periods of one month, two 

'Ballantyne, ''Introd. to Diseases of Inf.," Edinburgh, 1891, p. 194. 
2 Sutils, "Guide Prat, des Pesages," Paris, 1889, p. 58. 



GROWTH. 



19 



months, three months, four months, live months, six months, and so 
on. The following: table, extracted from one compiled by Mr. 
Charles Roberts,^ shows the average height and weight of children 



Fig. 1. 



MONTHS 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 lj5 

WEEKS 1 3 5 7 9 11 13 15 17 10 21 23 2o! 27 2'V31 33 35 37 3f> 41 43 45 47 40 i\\ w, CO o'j 0:1 7 


i; 


18 10 

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' of both sexes from five years old upwards. Under that age the rate 

^ of growth is the same, though boys are a little taller and heavier 

/ than girls. From five to ten years boys grow rather more rajiidly 

than girls, while from ten to fifteen the reverse is the case, owing to 

' "Med. Inspect, and Phys. Education in Schools," London, 1895. 



20 



INTRODUCTORY. 



a diminished rate of growth in boys. After fifteen years of age 
girls grow very slowly, and their full stature is gained at twenty 
years, three years earlier than in males. 



Height and Weight of 


Children from 5 to 15 Years of Age. 


Age last 


Height without shoes in 


Weight with clothes in lbs. 


Ratio : Weight divided 


birthday. 


inches. 




by height. 




M. 


F. 


M. 


F. 


M. 


F. 


5-6 


41.0 


40.8 


39.9 


39.6 


.97 


.97 


6 


44.0 


42.6 


44.4 


42.4 


1.01 


1.00 


7 


46.0 


44.5 


49.7 


46.7 


1.08 


1.05 


8 


47.1 


46.6 


54.9 


52.2 


1.16 


1.12 


9 


49.7 


48.7 


60.4 


55.5 


1.22 


1.14 


10 


51.8 


51.1 


67.5 


62.0 


1.30 


1.21 


11 


53.5 


53.1 


72.0 


68.1 


1.35 


1.28 


12 


55.0 


55.7 


76.7 


76.4 


1.39 


1.37 


13 


56.9 


57.8 


82.6 


87.0 


1.45 


1.51 


14 


59.3 


59.8 


92.0 


96.7 


1.55 


1.62 


15 


62.2 


60.9 


102.7 


104.8 


1.65 


1.72 



[It is interesting to note in this connection tables of weight and 
height in American children compiled by Rotch and Holt from the 
observations of Bowditch. 







Height ] 


n inches 






Weight in pounds. 2 


Age. 


















Williams. 1 


Rotch. 


Holt. 




Williams. 


Rotch. 


Holt. 


5-6 years. 


M. 
F. 


41.0 
40.8 






M. 
F. 


39.9 

39.6 






6 '' 


M. 


44.0 


43.75 


44.1 


M. 


44.4 


45.07 


45.1 




F. 


42.6 


43.35 


43.6 


F. 


42.4 


43.18 


43.8 


7 '' 


M. 


46.0 


45.74 


46.2 


M. 


49.7 


48.97 


49.5 




F. 


44.5 


45.52 


45.9 


F. 


46.7 


47.30 


48.0 


8 '' 


M. 


47.1 


47.76 


48.2 


M. 


54.9 


53.81 


54.5 




F. 


46.6 


47.58 


48.0 


F. 


52.2 


51.56 


52.9 


9 '' 


M. 


49.7 


46.69 


50.1 


M. 


60.4 


59.00 


60.0 




F. 


48.7 


49.37 


49.6 


F. 


55.5 


57.00 


57.5 


10 '' 


M. 


51.8 


51.68 


52.2 


M. 


67.5 


65.16 


66.6 




F. 


51.1 


51.34 


51.8 


F. 


62.0 


62.23 


64.1 


11 '' 


M. 


53.5 


53.33 


54.0 


M. 


72.0 


70.04 


72.4 




F. 


53.1 


53.42 


53.8 


F. 


68.1 


68.70 


70.3 


12 '' 


M. 


55.0 


55.11 


55.8 


M. 


76.7 


76.75 


79.8 




F. 


55.7 


55.88 


57.1 


F. 


76.4 


78.16 


81.4 


]3 " 


M. 


56.9 


57.21 


58.2 


M. 


82.6 


84.67 


88.3 




F. 


57.8 


58.16 


58.7 


F. 


87.0 


88.46 


91.2 


14 '' 


M. 


59.3 


59.8? 


61.0 


M. 


92.0 


94.49 


99.3 




F. 


59.8 


59.94 


60.3 


F. 


96.7 


98.23 


100.3 


15 " 


M. 


62.2 




63.0 


M. 


102.7 




110.8 


. 


F. 


60.9 




61.4 


F. 


104.8 




1084 



It would appear that American children are on the whole both 
taller and heavier than their English cousins. Observations by 
Porter, however, on St. Louis children show them to be lighter in 
weight til an those given above.] 

^ Without slices. 2 ^yj^i^ clothes. 



THE MORTALITY OF CHILDHOOD. 21 

The Mortality of Childhood. — It is not uncommoii to find the 
diseases of childhood made light of, and to hear the '' therapeutics of 
the nursery " spoken of with a certain scorn. The inliabitants of the 
nursery, however, are numerous. About one-third of the popula- 
tion is under fifteen years of age ; a quarter under ten, and these 
numerous inhabitants of the nursery are tlie hope of the future. 

The mortality among infants and children is enormous. More 
than two-fifths of the deaths in England and AVales during the ten 
years 1881-1890, occurred among children under the age of ten 
years. The greater part of this huge mortality took place under 
five years of age. With a mean popuhition under five years of three 
and a half millions, in round numbers, the deaths numbered two 
millions. In the same decennium there were nearly nine million 
births and over two million deaths. The annual death-rate per 
1,000 at all ages was 19.08 ; under five years it was 5(3.82. AVe 
must pass to the age period sixty-five to seventy-five — the Psalm- 
ist's span of life — before we again find the death-rate rising to so 
high a level. As the number of deaths in the first five years of life 
is greater than at any other period of life of the same duration, so 
the number of deaths in the first year of life is greater than in any 
of the subsequent years. Nearly a fourth of all the deaths regis- 
tered in the decennium were those of infants under one year — a 
million and a quarter out of a total of five millions and a quarter. 
In the German Empire in the two years 1892-93 the deaths in 
infants one year old and under exceeded a third of the total number 
of deaths. It will be instructive to indicate briefly the main causes 
to which this excessive mortality in infants and children was at- 
tributed. 

If the annual mortality per 1,000,000 living at all ages and at 
childish ages in England and AVales be compared, it is seen that the 
rate in childhood in the decennium 1881-90 was in excess in the 
following classes of causes : — 



()-o. I 5-10. i 10-15. All ages. 

' Respiratory diseases 12,966 

j Acute specific diseases 9,130 

, Nervoas diseases 8,337 

I Diarrhfeal and digestive diseases 7,308 

I Tubercle..... 4,499 

Violence. , 1,142 

The influence of infectious processes is even greater than appears 

' from the table, for under the head of nervous diseases are included 

cases of intracranial tubercle, and diarrhoea accounts for considerably 

I more than half the deaths due to diarrhoeal and digestive diseases. 



853 


i 213 


3,729 


1,839 


541 


1,667 


578 


320 


2,592 


279 


177 


1,778 


844 


, 827 


2,420 


325 


263 


648 



INTRODUCTORY. 

With repird to diseases of the respiratory system also there can be 
little doubt that a very large proportion was due to infective forms 
of broncho-pneumonia. Further it will be seen that the enormous 
excess in the death-rate in childhood is due almost entirely to its ex- 
cess in children under five years. In the other two quinquenniads 
of childliood the death-rate is below the average, with the single ex- 
ception of the rate from acute specific diseases at the age-period five 
to ten. The classes of disease the death-rate from which in childhood 
is lower than the average at all ages are, in fact, few. The most im- 
portant are : — 



1 0-5. 


5-10. 


10-15. 


All ages. 


XJrin{\rv system 


193 


92 

149 

10 


62 

258 

11 


435 




134 


1,576 


Cancer 


! 20 


589 



Sex. — Since the generative system is very far from its full develop- 
ment in early childhood, it might have been expected that the death- 
rates of the two sexes would have shown little or no diiference. 
This, however, is not the case. The common opinion of matrons 
that male are more difficult than female infants to rear is borne out 
by statistics. The annual mortality among males is greater than 
among females at all age-periods except from ten to twenty. The 
disparity is greater under five years of age than at any other period, 
except at sixty-five and upwards : males, 61.69 per 1,000 ; females, 
51.99 per 1,000. The death-rate under one year of age is, per 1,000 
births, males 155, females 128. The mortality in the two sexes per 
1,000,000 living from the causes in respect of which childish mor- 
tality is in excess of the average, is shown in the following table : — 





0-5. 


5-10. 


10-15. 


All ages. 




M. 


r. 


M. 


F. 


M. 


F. 


M. 


F. 


Respiratory diseases.... 


14,141 


13,799 


846 


821 


211 


215 


4,096 


3,382 


Acute specific " 


9,008 


9,252 


1,735 


1,939 


495 


583 


1,694 


1,641 


Nervous " 


9,451 


7,231 


601 


556 


322 


318 


2,804 


2,392 


Diarrhwal and diges- 


















ti ve diseases 


8,007 


6,614 
3,991 
1,019 


263 


293 


188 


1fi8 


1 875 


1,687 

2,229 

347 


Tubercle 


5,010 


815 


872 


627 


1,026 
91 


2 fi29 


Violence 


1,266 


451 


199 


435 


968 



These statistics and others quoted above are compiled from the Decennial Sum- 
mary, 1881-90, of the Registrar-General.' 

It will be seen that the number of deaths attributed to acute spe- 
cific fUsen8P.s is greater among girls than among boys throughout 
childhood ; that at ages five to ten years diarrhoeal and digestive dis- 
eases are rather more fatal to girls ; and that tubercle, which is rather 



SLEEP. 23 

more fatal to them than to boys at the age-period five to ten, is much 
more fatal to them at the age-period ten to fifteen. AVith these ex- 
ceptions, however, the death-rate of boys is higher at each age from 
each of the most important classes of diseases. Under five years the 
greater mortality of boys from respiratory, nervous, diarrlnt^al, and 
tuberculous diseases is very remarkable. Xo adequate explanation 
of this disparity, which appears in all the statistics with which I am 
acquainted, has been given. It has been urged that the fact that 
male infants are on the average heavier than female renders them 
more liable to injury at birth, but this can hardly be held to account 
for their higher mortality from respiratory and diarrhoeal diseases, 
and is no explanation of the fact that the death-rate of boys from 
tubercle is greater by one-fourth. Nor does the suggestion that 
males are more exposed to the vicissitudes of life appear a sufficient 
explanation, since there is very little diffi^rence in the management of 
children of either sex under five years of age ; and at the age-period 
ten to twenty, Avhen this cause might be imagined to be most opera- 
tive, the difference in the death-rate is in favor of males. 

Sleep. — An infant in good health sleeps seven, eight, or nine 
hours by night, and for an hour or more between each suckling by 
day. The cradle in which it passes so much of its life during the 
first year is, therefore, deserving of attention. It should be light 
and easily cleaned. Many cradles are much too deep. This leads 
the nurse to wrap the infant in a blanket, and then put a blanket 
and coverlet over the sides of the cradle ; as there is usually a curtain 
or hood at the head, the infont lies sweating at the bottom of a cavity 
closed below and very much obstructed above. All bed-clothing 
should be of woollen, and if the outer covering must be ornamental a 
colored or embroidered blanket should be selected. An infimt should 
not sleep in the same bed with its mother or nurse. Apart from the 
fact that a large number of infants are annually suffocated or crushed 
by being overlaid in bed, the practice is objectionable because the 
infant is apt to be overheated and deprived of its share of air by 
being buried under the bed-clothes. It has the further drawback of 
tending to encourage the vicious practice of permitting the infant to 
suckle at odd times, or at short intervals, during the night. 

During the second and third years of life a healthy child will con- 
tinue to take part of its sleep by day, and the custom of making a 
child at least lie down, if it do not sleep, in the middle of the day, 
until five or six years of age, is a good one. The night's sleep at 
three years of age should be for about eleven or twelve hours. If 
left to itself the child will as it grows older, begin to shorten its 
night's sleep by waking up a little earlier in the morning. It is 
much better to allow this shortening of the hours of sleep to be thus 
spontaneously effected than to permit the child to sit up later in the 



24 INTRODUCTORY. 

Q\vniu<r. Most children of school age, especially among the poorer 
classes, do not get enough sleep. A child of ten years needs at least 
ten hours, which means fully eleven hours in its bedroom ; if break- 
fast is to be at eight a.m. the child should, therefore, ''go to bed'^ at 
nine p.m. Every child should have a separate bed, and, after the 
age of ten years, a separate bedroom or cubicle. 

The nursery in which an infant lives so large a part of its time 
should be spacious, and well w^armed and ventilated. It should be 
furnished simply, all floor coverings should be easily removed, and 
the whole room kept scrupulously clean. The floor should receive 
special attention, for the infant when it begins to crawl will carefully 
examine every object which it comes across by putting it into its 
mouth. 

After the first fortnight a healthy infant should spend at least 
three hours a day in the open air, and, short of falling rain or snow, 
there are in temperate climates no weather conditions which should 
keep it indoors. 

Clothing. — It seems to be the rule in tropical climates to dispense 
the indigenous infants and young children from clothing of any kind ; 
but it is a curious circumstance that in temperate and cold regions 
the practice appears to have been universal of wrapping infants in 
swaddling clothes which seriously impeded the movements of the 
lower limbs, and, under some systems, of the upper also. This cus- 
tom probably had its origin in the recognition of the fact that one of 
tlie primary needs of infancy is warmth. Provided that it be kept 
warm and supplied with its natural nourishment an infant will com- 
monly flourish under circumstances in other respects most adverse, 
showing an imperviousness to injurious influences and an immunity 
from many infectious disorders, w^hich are really remarkable. 

The clothing of an infant should be, in the main, of woollen ma- 
terials,^ but the custom of using a garment of fine linen (cambric) or 
cotton next the skin of the trunk has much to recommend it. The 
use of a binder, either of woollen or knitted material, applied so as 
to cover the whole of the abdomen, is customary, but is more neces- 
sary in infants and children whose skirts have been shortened than 
in the young infant, which is usually enveloped in voluminous petti- 
coats. The napkin to catch the urinary and alvine secretions should 
be of soft cotton diapering or tow^elling. It should be renewed as 
often as it is soiled, and all forms of w^aterproof retainers should be 
avoided, except under such special circumstances as a journey. When 
a child reaches the age of eighteen months or two years, the fault 
most often committed is to make its clothing too heavy, and too de- 
pendent by straps from the shoulders, while the belly and thighs are 

I The belief that it is difficult to wash woollen materials without causing them to 
shrink is a myth fostered by incompetent laundresses. 



CHANGE OF AIB. 25 

often left uncovered or insufficiently protected. A binder, or soft 
woollen c^arment fitting closely to the belly, is an essential ])recaution 
at almost all seasons of the year in temperate climates. The legs 
should be covered by long knitted drawers, open back and front ; and 
the arms by sleeves attached to the dress, or by a sleeved jacket. 
Even when the child is older parents are very apt to neglect to pro- 
vide adequate clothing for the lower part of the body, Avhile at the 
same time they often overload the chest. 

Baths. — Great pains should be taken to keep an infant clean, but 
it is possible to bathe and wash too much. Under the head of the 
treatment of the specific fevers by baths will be found some observa- 
tions on the very considerable effect on the body temperature which 
even lukewarm baths may have. In feeble infants the exposure 
necessary to give a complete bath may produce a degree of depression 
which should be avoided. In such cases the child should be washed 
piecemeal on the nurse's lap before a good fire. A healthy infant 
should be washed every morning ; it is first lathered with a soapy 
flannel on the nurse's knee, then held in a sitting posture in the bath 
or basin and sponged rapidly. Many infants are all the better if this 
washing be repeated in the evening. The buttocks and perineum 
should be cleansed with hot water and soap after each action of the 
l)Owels, the parts dried with a soft towel, and dusted Avith starch 
powder. A full warm bath at about 90° F. may be given daily to 
a healthy infant at the age of six months, and the infant may gradu- 
ally be accustomed to a lower temperature by making use of cool 
affusion at the moment of its being taken out of the bath. At or 
about the age of five years a cold bath may be agreeable to the child 
in warm weather, but if it show a dislike for the cold bath it is bet- 
ter to continue the use of warm water followed by cold sponging. In 
any case, the whole process of soaping, bathing, drying, and dressing 
should be carried through as quickly as possible in a warm room. 
In England the morning cold tub has been raised to the dignity of a 
national custom, but in childhood as in old age it is more often in- 
jurious than beneficial. 

Change of Air. — If an infant reside in the country, annual change 
of air is certainly not necessary, and is frequently undesirable. Dur- 
ing the first two years the nursery in which it lives is a more impor- 
tant source of well-being than change to the seaside. For town-l)red 
infants a change to the country during the hot weather, when the air 
<»f large cities is charged with dust, is certainly desirable. Children 
of two years old and upwards who can run alone are greatly benefited 
by residence, fi>r some m(»nths annually at least, in the country, wliere 
greater freedom can l)e allowed and where, in consequence, they spend 
the greater part of the houi-s of daylight in the open air. Children of 
a " scrofulous " disposition, and those who are anaemic, marasmic, or 



26 



INTRODUCTORY. 



ill-grown, cmiimonly derive great advantage from residence for some 
montlis in every year at the seaside. For such children the east coast 
of Enghind offers special advantages. The north coast of France 
j)ossesses a similar, but somewhat milder, climate. To obtain the full 
advantage of sea air in scrofulous diseases, enlarged tonsils, and other 
disorders of the lymphatic tissues, it is necessary that the patient 
should reside within fifty yards of high water mark, and that the 
interspace should be free from buildings and other obstructions, or, 
as an alternative, that the hours of daylight should be spent on the 
beach. Children Avith a rheumatic or gouty tendency generally do 
better inland on a dry, porous soil. For children of a highly nerv- 
ous organization the seaside is usually too stimulating. For them, 
at least, sea bathing is not to be recommended, and no child should 
be forced to bathe in the open sea against its will. The custom of 
permitting children at the seaside to spend many hours a day pad- 
dling with bare feet and legs is dangerous, and has been responsible 
for many attacks of diarrhoea and various congestive disorders of the 
viscera. 



CHAPTER 11. 
CLIXICAL EXAMIXATION. 

Clinical Examination of Infants and Young Children — General Observations — 
Physical Examination of the Upper Air Passages — Of the Chest — Of the Circula- 
tory System — Of the Abdomen — Of the Head — Eetraction of the Head — The 
Temperature in Infancy and Early Childhood. 

Clinical Examination of Infants and Children. — In the treat- 
ment of the diseases of infants and young children the physician must 
rely almost entirely upon his own observations of the symptoms and 
physical signs presented by the patient. Infants can give no infor- 
mation directly, and the statements of young children as to the seat 
of pain or discomfort are commonly very indefinite and untrust- 
worthy. 

Careful inquiries as to the past history of the child should be made, 
and the value to be attached to the statements made must be esti- 
matal after taking into consideration the intelligence and mental or- 
ganization of the mother or nurse. An irritable, hysterical, or un- 
principled woman may grossly, if sometimes unconsciously, exaggerate 
or minimize the degree and amount of ill-health from which the pa- 
tient has suffered. The family history will often throw much light 
on the constitutional peculiarities and tendencies which the child 
may be expected to have inherited to a greater or less degree. Un- 
doubtedly, the early demise of many other children of the same 
family aggravates the prognosis, whether the deaths have been due 
to constitutional defect or to ignorance and incompetence in the 
mother. It is desirable to make a note as to all the previous preg- 
nancies of the mother; a syphilitic taint may thus be suggested 
which might otherwise escape detection. Again, many deaths from 
intestinal disorders may point to radical defects in the sanitary sur- 
roundings, or in the method in which the mother cares for and feeds 
her offspring. 

Statements as to the infectious diseases from which a child has 
suffered previously must be received with a certain amount of cau- 
tion. With regard to measles, in particular, mistakes are often 
made ; in mild cases of fever, with a rash resembling measles, med- 
ical assistance may not have been obtained, although the mother 

27 



28 CLINICAL EXAMINATION. 

inav subsequently feel justified in making a most positive statement 
that the child has suffered from measles.^ 

An injant, especially if the disease be of chronic character, should 
first be seen dressed fully, because faults in dress are fertile causes 
of illness. Much may be learnt from the general appearance and 
movements of the infant. A healthy infant, when awake, is, except 
perhaps immediately after suckling, in almost constant movement ; 
the hands and upper and lower limbs are continually in motion. Its 
gaze moves slowly and uncertainly from one object to another ; it 
grasps a finger firmly, and shows a strong disposition to carry any 
object placed in its hand to its mouth, and is provoked to smile even 
more readily than to cry. 

Short, sudden cryiugs, especially if they come on soon after feeding, 
and are accompanied by drawing up of the thighs to the abdomen, 
usually indicate gastric disturbance and flatulent colic. The infant 
will usually take the breast readily, even greedily, and is, therefore, 
often supposed to be hungry. Persistent crying, attended by some 
blueness about the lips, and disinclination to take the breast, will 
often be found to be due to intestinal disturbance, and will be fol- 
lowed by diarrhoea, or relieved by an evacuation produced by castor 
oil. A flushed and perspiring face, with increased rapidity of 
breathing, will suggest bronchitis ; rapid, regular breathing, with an 
anxious expression and pallor or irregular flushing of the face, 
pneumonia. It would be easy to enlarge on the information obtained 
from a study of the physiognomy of disease in infants and young 
children, but personal observation alone can afford any profitable 
knowledge. Suffice it to say that the assistance to be obtained from 
a careful examination of the manner, attitude, and general appear- 
ance is never to be despised. 

AVhile the infant is being undressed, information may be obtained 
as to the existence of general or local tenderness, and as to the mo- 
bility of the limbs. The chest and abdomen should be quite denuded 
of clothes, including the belly band, and the infant should then be 
wrapped in a blanket. The front should first be examined with the 
inflint lying on the nurse's lap. It should then be lifted up so that 
its belly rests against the nurse's chest and its head looks over her 
shoulder ; the back is thus brought Avell into view. Or the infant 

' Certain phrases are so commonly used by nurses and mothers of the poorer classes 
in Great Britain with fairly well-defined meaning that it may be worth while to 
mention some of them. Tlius " windy spasms" signifies abdominal pain with eructa- 
tion, or expulsion of flatus from the anas ; " inward convulsions " usually colic, with 
spasmodic or jerky movements of the arms and drawing up of the leg, sometimes 
slight eclampsic or epileptic attacks, sometimes respiratory spasm ; *' convulsion fits" 
signify marked eclampsia as a rule ; ''taken off his feet," that a child who has once 
walked has ceased to care to do so, a common symptom of early rickets. The phrases 
vary in different localities, and it is of some importance to become acquainted with 
them. 



CLINICAL EXAMINATION OF INFANTS AND CHILDREN 29 

mav be placed face downwards on the nurse's lap, or on a bed with 
a pillow under its chest and belly. The infant should next be re- 
placed on the lap and the napkin removed for inspection and palpa- 
tion of the buttocks and anal region. Lastly, the mouth and 
throat should be examined in a good light, a manoeuvre which com- 
monly leads to crying, and which should, therefore, be deferred until 
the end of the examination. The whole should be done speedily but 
gentlv, and without jerks — festina lentc. Auscultation of the chest 
and palpation of the abdomen ought to be accomplished before the 
infant begins to cry. Sudden movements, or anything like rough 
handling, will precipitate the almost inevitable protest from the pa- 
tient ; but firm palpation, if gently applied, is very well borne 
until some area of tenderness is reached, and valuable information is 
thus gained. It is, as a rule, waste of time to seek to conciliate a 
young infant, or to divert its attention. This duty is better rele- 
gate<l to the nurse. 

AVith children, however, the opposite is the case, and every eifort 
should be made to establish friendly relations or, at least, to disarm 
active opposition. The first essential is to give the child time enough 
to come to his own conclusions as to the unaccustomed visitor, and 
the interval may be utilized in gathering the history of the illness 
from the mother or nurse ; this plan has the additional advantage of 
diverting her attention from the child, who is thus left quite undis- 
turl>ed to complete his examination of the physician, which, it must 
always be remembered, must be allowed to precede the examination 
of the patient by the physician. In children under the age of five 
or six years, the routine to be followed in making a physical exami- 
nation should be very much the same as for infants, and in every 
case every part of the person should be examined by the eye and 
touch. It is best, therefore, if no objection is raised, to have the 
child stripped and rolled in a blanket, and as many children very 
much dislike having their clothes taken off, it is often wisest to see 
the patient in his cot, which should be In'oughtinto a good light and 
one side removed. In children over eight to ten years of age tlie 
physical examination may, as a rule, be carried out as in adults. 

In treating an infant or child presenting symptoms of catarrh or 
obstniction of the upper air passage, it is essential to make a careful 
examination of the pharynx. The patient should be seated in a good 
light on a stool or on the nurse's lap; the nurse, standing or sitting 
behind the patient, should grasp one of the child's wrists in either 
hand, and its back and shoulders should rest against her chest or 
arm, so that its head falls backward. The child should then l)e 
induced to ojx'u its mouth and, care l>eing taken that the tongue is 
within the line of the teeth, the depressor should be rapidly intro- 
duced and the tongue pushed gently but firmly downward. A com- 



30 



CLINICAL EXAMINATION. 



ploto but brief view of the palate, tonsils, and pharynx will thus be 
obtained before the child begins to swallow or cry. Prolonged in- 
spection always causes much distress, and generally fails in its object. 
If the first glance does not give the desired information, it is better 
to wait a short time and repeat the manoeuvre. In making applica- m\ 
tions to the throat the same method should be followed. f | 

Laryngoscopical examination is, in infants and young children, 
exceedingly difficult owing to their restlessness and the small size of 
the parts, which in cases calling for such examination are usually 
swollen and more sensitive owing to the presence of catarrh. A 
small mirror must be used, and, at most, a very fleeting view of the 
larynx can be hoped for. 

Laryngeal obstruction when it produces dyspnoea causes recession 
during inspiration of the tissues in the suprasternal notch, in the 
intercostal spaces, and of the lower part of the front of the chest. 
In young children, owing to the elasticity of the costal cartilages, 
the recession is most marked in the last-named situation, each in- 
spiration being accompanied by a depression of the epigastrium and 
the lower part of the sternum and adjacent costal cartilages. In 
rickety children the area over which the recession occurs may be 
considerably larger, the whole of the lower part of the chest in front 
being drawn in, and the upper part of the sternum thrust out. The 
recession in this and the other situations mentioned is due to the in- 
crease in the negative pressure within the thorax with each inspira- 
tion owing to the obstruction to the entrance of air, and the forcible 
action of the muscles of respiration. At the lower part of the chest 
this is reinforced by the pull of the diaphragm on the ensiform carti- 
lage and the lower costal cartilage. 

When called to treat a child supposed to be suffering from disease 
of the respiratory organs, a thorough examination should be made on 
the first occasion. For this purpose the patient should, if possible, 
be seen under natural conditions, as any excitement causes a disturb- 
ance of pulse and respiration. Particulars as to the date, mode of 
onset, and general character of the indisposition should be ascer- 
tained, but too much reliance must not be placed on the history. The 
general aspect of the child, the color of its face, the existence or not 
of restlessness or great depression, and the presence or absence of 
dyspnoea, must be noted. Some insight into the nature of the dys- 
pnoea, if present, may be obtained. Thus, the inspiration may be 
attended by laryngeal stridor, or the voice may be hoarse ; or, again, 
it may be noticed that the child breathes through the mouth — and 
this, if respiration be not greatly hurried, points to obstruction in 
the nose or naso-pharynx. An infant should be put to the breast 
in order to observe whether it is able to suckle without the frequent 
pauses which nasal obstruction produces. 



CLINICAL EXAMIXATIOy OF INFANTS AND CHILDREN 31 

The diagnosis of disease of the respiratory organs in the infant and 
chiUl mnst be based alm(»st entirely on physical examination ; this, 
however, it is not generally possible to conduct in the methodical 
manner which may be followed in the adult. A young child may 
permit itself to be looked at, but unless unusually well and good 
tempered, or very ill, it is apt to resent auscultation a good deal, and 
palpation and percussion even more. In older children — say over 
two years old — the examination is best conducted with the child sit- 
ting on a high stool — if with a revolving top, so much the better. 
Unless the child be greatly exhausted, or show a natural disposition 
to lie down — and it is remarkable how acutely ill a child may be, 
and yet prefer to sit up or recline in its mother's lap — it is better not 
to have it in a recumbent attitude when examining the chest. 

Inspection of the chest may afford much valuable information. 
The rickety rosar}' will indicate undue softness of the thoracic walls, 
and afford an important element in prognosis. Recession at the 
bases, particularly in front, and in the suprasternal notch, will indi- 
cate that air is entering the lungs with difficulty. The degree to 
which respiration, in the healthy child mainly abdominal, has been 
reinforced by thoracic movement or by the action of the accessory 
muscles will be observed, and any inequality in the expansion of the 
two sides can also frequently be noted. Some opinion also can com- 
monly be formed as to the respiratory rate. This, in health, is faster 
in the infant and child than in the adult ; and is in inverse ratio to 
the age of the child. The new-born infant makes from thirty to fifty 
respirations a minute, at one year the rate has fallen to twenty-five 
"T thirtA'-five. It is somewhat slower during sleep, is easily altered 
by various circumstances, and is frequently somewhat irregular, with 
comparatively long pauses. If the respiratory organs be diseased, 
the breathing is commonly increased in rapidity, is regular and com- 
paratively easy to count. The existence of distension, flatulent or 
otherwise, of the abdomen may also be observed. 

AiLf(cnUat'wn is, as a rule, best performed next in order. It should 
be conducted rapidly, and care should be taken that the hands are 
warm and soft. Though many still use the wooden stethoscope for 
one ear, preferring it on the ground that its use is attended by fewer 
adventitious sounds, it is l^etter to l)ecome accustomed to the use of 
the binaural stethoscope, since the chest of a child can be examined 
with it much more rapidly, and the risk of hurting it by undue pres- 
sure is much less. A little practice in the examination of the chest 
in healthy infants and children will fpiickly train the ear to disregard 
the adventitious sounds, which, moreover, are really fewer than with 
the wrK)den stethoscope. The fingers brought into contact with the 
'^hest gather a certain amount of information as to its elasticity, and 
- to the existence of fremitus or tenderness, while the physician sees 



CLINICAL EXAMINATION. 



precisely the area over which the sounds he hears are present. In 
oxamining the chest of an infant it is best to commence with the 
front, the patient lying in an easy attitude on its mother's lap. At 
the same time one axilla may be auscultated. Next, the infant should 
be placed on the upper part of the nurse's chest, with its hands and 
head resting lightly on her shoulder, and its buttocks supported by 
her hands. In this way the back is thoroughly accessible, and can 
be rapidly auscultated, as can also the other axilla. In children on< 
year old and upward it is best to begin w ith the back, the child being 
in the sitting posture, and to examine in succession the supraspinous 
and interscapular areas, at the angles of the scapula, and the base. 
In the earliest Aveeks of life the breath sounds are weak, but there- 
after become gradually louder and harsher ; so that at about six 
months of age the vesicular murmur is louder, higher pitched, and 
rougher, almost blowing, and expiration may be distinctly audible — 
the condition to which in the adult the term " puerile breathing " is 
applied. Each axilla may be auscultated from below upward, and 
finally the front of the chest from above downward. 

Palpation may then be rapidly completed by placing the hands on 
the two sides to detect any inequality of expansion ; to estimate the 
heat of the skin ; and to complete observations as to the existence of 
rickety deformities or undue softness. The position of the apex-beat 
should also be ascertained. 

Percussion should be lightly performed. The younger the child, 
the less the importance to be attached to variations in the percussion 
note, unless the alteration be very marked. In a healthy infant, 
breathing calmly, the percussion note is almost tympanitic. But 
when it is beginning to cry, the abdominal pressure forces up the 
viscera, the liver in particular, and the note becomes somewhat dull 
over the left base, and flat and short over the right. Percussion over 
the upper parts of the chest, especially in front, wdll, if too forcible, 
produce a ^' cracked-pot " sound. 

The pulse in early infancy is rapid — 120 to 150 — and easily quick- 
ened. It is difficult to count it at the wrist, but the rate and general 
character can be ascertained by auscultation. The rate and force of 
the heart are easily disturbed, so that not much information of gen- 
eral clinical value can be obtained from its examination. The first 
sound is short, and toneless as compared with that of the adult, and 
the second less sharp, owing, probably, to the low arterial tension 
characteristic of infancy. During the second year of life the pulse still 
is fast, over 100, but becomes slower in the third year, and falls to the 
adult average at about the seventh year, by which age also the sounds 
have assumed their characteristic qualities. Pathological slowing of 
the pulse is not common in infancy and early childhood, and when ob- 
served is usually associated with tuberculous meningitis or jaundice. 



RETRACTION OF THE HEAD. 33 

The abdomen in the infant is hirger in proportion to tlie rest of the 
IxkIv than in tlie adnlt, and owing to the small size of the pelvis is 
rendered more protnberant. This protnberanee, however, is towards 
the front, and the sides of the belly shonld not be visible when the 
ehild is regarded direetly from the baek. In health it is firm and 
uniform to the tonch, and if the infant is in a good temper, to begin 
with gentle manipnlation ap])ears to give it pleasnrable sensations. 
Veither the liver nor the spleen ean be perceived with any eonfidence. 
llie liver ocenpies nearly half of the abdominal eavity ; its lower 
lx)rder reaches from the left hv])ochondrium across the epigastrinm 
almost horizontally to the right hypochondrinm, descending in the 
flank a little lower on the right than on the left. Emaciation, or 
laxness of the abdominal walls due to past distension, renders it easy 
to palpate the lower border. Under similar circumstances the spleen 
when enlarged is easily felt, usually best by slipping the pulps of the 
fingers obliquely over the edge of the thorax, and carrying them 
downwards ; if the one hand be placed under the flank and the other 
used for palpation from the left side, the spleen may easily be pushed 
out of the way, and missed even when moderately enlarged. The 
movements of the abdomen in respiration should be free, and their 
absence points to serious abdominal disorder, and probably to in- 
volv^ement of the |>eritoneum. The existence of gurgling in the 
intestines and of enlarged glands will also be ascertained during pal- 
pation. Great flatulent distension of the intestines renders the belly 
more or less globular, tense, and tympanitic on percussion. In 
chronic gastro-enteritis the lower part of the belly feels doughy ; 
while in the upper part there is often tension, and a tympanitic per- 
cussion note owing to flatulent distension of the stomach and colon. 
Marked retraction of the belly combined with softness to the touch 
\\ ill suggest tuberculous meningitis {q. r.). 

Examination of the head will show the condition of ossification, 
and tlie presence or absence of cranio-tabes. The condition of the 
anterior fontanelle, whether tense or retracted, will afford informa- 
tion as to the state of the circulation, which is often more valuable 
than that given by the pulse or heart sounds. 

Retraction of the Head. — In infants and young children the first 
symptom <>f meningitis to attract attention may be retraction of the 
head and rigidity of the muscles at the ])ack of the neck. Tiiis is due to 
meningitis of the jx)sterior fossa; if the inflammation extend into the 
spinal canal the tonic rigidity involves also the muscles of the back. 
The cause f>f the inflammation is not always to be ascertained. In some 
cases it is tuberculous, and the more general sympt(>ms of tuberculous 
meningitis follow. Cases running a veiy chronic course have been 
attributed to syphilis. Retraction of the head, dating from birth, is 
attributed by Gowers to meningeal htenifjrrhage in the neighborhood 
.3 



34 



CLINICAL EXAMINATION. 



of the medulla, or to laceration of the cerebellum. Tumor in this 
reg-ion may also cause retraction. Instances of retraction of the head 
in infants, slight in degree and short in duration, are sometimes met 
with, and are apparently functional ; such children sometimes pre- 
sent symptoms of tetany [q. v.). Pneumonia of the apex is in many 
cases accompanied during the stage of onset by more or less marked 
retraction of the head. Rheumatism of the muscles of the neck and 
back, and acute or sub-acute cervical adenitis are among local causes 
of retraction. Middle ear disease and certain peripheral irritations, 
especially gastro-intestinal disturbance, and infestations by intestinal 
worms (ascaris), may also determine retraction, though probably 
such cases should be classed as examples of tetany. The retraction 
may be slight and intermittent, or extreme and constant, so that the 
occiput is in contact with the back. The infant lies on its side if in 
a cradle, but prefers to be nursed, the mother's arm supporting the 
head. When put into the sitting posture the retraction becomes 
greater, and the infant evidently suifers pain. 

Fever. — The main sources of the body heat are the muscles and 
the abdominal organs ; the main sources of loss the skin and lungs, 
mainly the former. Fever is produced by toxaemia, the poisonous 
substances acting, possibly directly on the metabolic processes of the 
tissues, and certainly indirectly by disturbing the heat-regulating 
nervous mechanism, which presides over both the production and the 
loss of heat. As Broadbent has well said, the fact ^^ that febrile heat 
is not vague and irregular, but that there is the substitution of a mor- 
bid for a normal balance, is evidence of nervous control." During 
the febrile process there is increased loss of carbonic acid by the 
lungs and of nitrogen by the urine. At the same time, there is an 
arrest of the digestive secretions, so that with increased destruction 
and diminished assimilation there is necessarily a more or less rapid 
wasting of the tissues and diminution of their functional activity. 

The temperature in childhood is easily affected. Slight disturbance 
may cause it to rise above the normal, and the height to which it 
may be raised may be out of proportion to the severity of the patho- 
logical process. The converse proposition that the temperature in 
(childhood is easily reduced when abnormally high is true also as a 
general statement. It would, however, be a mistake to regard lightly 
the presence of high temperature in childhood. A single observation 
may have little significance, but if the pyrexia continue it is as defi- 
nite an indication of the existence of disease as in the adult. On the 
whole, the greater the care with which patients are examined the 
more rarely will paradoxical temperatures be met with. On the 
other hand, it must be remembered that causes which in the adult 
would lead to a rise to perhaps 100° F. will, in infants and young 
children, produce temperatures of 103° to 10e5° F. This is more 



FEVER. 35 

esjx'ciallv true in its application to children of excitable tempera- 
ment. 

Subnormal fcmpcrafurc, when observed in childhood, is nsnally a 
svmptom of marasmus, and is a bad omen as a sign of great nervous 
exhaustion. Under careful treatment, however, infants may survive 
temperatures as low as 9G° F., or even lower. 

Fever, to whatever cause it may be due, renders the patient spe- 
cially liable to various secondary attections ; in particular, to broncho- 
pneumonia and to gastro-enteritis. 



CHAP 
DISEASES INCIDENTAL TC BIRTH. 

H£emorrliagic Extravasations during Parturition ; Meningeal Hsemorrhage — Icterus 
Neonatorum — Acute Fatty Degeneration of the New-Born — Acute Hsemoglobi- 
nuria of the New-Born — Mastitis — Erysipelas Neonatorum — Erythema Neonato- 
rum — Diseases of the Navel — Tetanus Neonatorum — Sclerema Neonatorum — 
Q^^dema Neonatorum — Melaena Neonatorum — Pemphigus Neonatorum — [Hem- 
orrhagic Diseases of the New-Born]. 



Hsemorrhagic Extravasations During Parturition. — During the 
act of parturition haemorrhage may occur into the skin, subcutaneous 
tissues, muscles, or viscera of the infant. 

The causes are to be sought (1) in the great delicacy of the vessels ; 
(2) in the force exerted by the uterus on the child, which may be 
compressed strongly against the maternal parts, while the blood may 
be squeezed mechanically into certain organs ; and (3) in pressure or 
traction exerted by the hand of the obstetrician or by forceps. As- 
phyxia, which is capable of producing sub-serous petechise, will have 
the eiFect of reinforcing other causes tending to produce haemorrhage 
into the substance of organs. 

Cephalhaematoma is the term applied to the effusion of blood 
which often takes place between the skull bones and their periosteum. 
The bone most often affected is the right parietal, next to that the 
left, more rarely the occipital, frontal, or temporal. The haemor- 
rhage is limited by the attachment of the periosteum at the sutures, 
but both parietal bones may present blood tumors. The swelling 
continues to increase for some days after birth. It is soft and 
fluctuating, and by deep pressure the underlying bone may be felt. 
After a time the edge becomes hard, and eventually the periosteum 
forms a ring of bone all around the hsematoma. Plates of bone may 
also form in the periosteum over the fluid, and give a crackling sen- 
sation when the swelling is handled. The blood is absorbed in the 
course of a few weeks, but the ring of bone persists much longer, 
often for many months. Occasionally the external effusion is as- 
sociated with hemorrhage between the skull and the dura mater, and 
a connection may exist between the two collections. 

The diagnosis is usually easy. A question hardly arises until after 
the time at Avhich a caput succedaneum would have disappeared. 

36 



MENINGEAL HAEMORRHAGE. 37 

C'ephalhieniatoma is, in fiict, distinguished from ail other conditions 
witli which it might be confused, with the singk^ excei)tion of menin- 
uocele (or encephalocek^), by the date of its appearance and the ex- 
istence of fluctuation. ^leningocele, however, corresponds in situa- 
tion with a fontanelle or suture, pulsates, and becomes more tense 
when the child cries. ^loreover, the a})erture through which it 
protudes can be made out, and ought not to be confused with the 
bony ring around a cephalhtematoma ; moreover, in the latter con- 
lition the underlying bone can be felt. The prognosis is good unless 
symptoms exist pointing to the concurrence of intracranial haemor- 
rhage. 

The treatment shoidd consist in protecting the swelling from in- 
jury. Incision is unnecessary, and no local or internal medication 
i- known which will hasten the disappearance of the effused blood. 
This will take place in time, and the bony ridge will gradually dis- 
ap]X'ar also. 

Meningeal Haemorrhage is the most important of the extravasa- 
tions whicli attend birth, owing to the fact that it produces serious 
permanent symptoms should the child survive. Compression of the 
skull during parturition may cause congestion and oedema of the 
cerebral meninges and of the brain substance, with or without 
hiemorrhage into or beneath the membrane. Haemorrhage between 
tlie skull and dura mater occurs in association with fracture. 
Hiemorrhage into the ])ia mater or arachnoid is the most frequent 
lesion in infants dying in consequence of injury during parturition. 
In most cases blood is effused over the convexity on both sides and 
at the base, sometimes on one side only. In rare cases, haemorrhage 
takes place into the ventricles or choroid ])lexus, or into the sub- 
stance of the brain. Judffincr from the conditions found in still-born 
infants, intracranial haemorrhage occurs more frequently in those 
delivered by the forceps ^ than in those born by the breech, and in 
the latter more frequejitly than in those born naturally by the head. 
It may occur during rapid delivery as well as slow, in imdtipanc as 
well as in primipane, in small as well as in large children. 

The lesions of the spinal cord found in still-born children are 
ingestion of the whole, or of the anterior cornua, or of the surface, 
lud lijcmorrhage outside the theca into the meninges, or into the 
•onl (especially the anterior cornua). The lesions of the fihdoniluaf 
n'fffiiiftj which may be produced during birth, may be enumerated as 
lolhtws: Liver: Congestion of the substance, haemorrhage at the 
-urface. Kidnerji* : Congestion with or without hjcmorrhage into the 

' I Ierl)ert Spencer, to whose article ( Tram. Ohstef. Soc, vol. xxxiii. ) I am much 
indebted, makes the remarkable statement that "cerebral Ivrf'morrhape was found in 
very ca««e in which the forceps was employed to deliver livin/,' chilclren who died 
luring or shortly after birth." 



38 DISEASES INCIDENTAL TO BIRTH, 

hilum, beneath the capsule or into the substance. Haemorrhage into 
the pwamidal portion may be a cause of suppression of urine and 
(.loath a few days after birth. Suprarenal capsules : Congestion with 
or without haemorrhage. Spleen: Congestion, haemorrhage (rare). 
Intestines : Contain blood occasionally ; the stomach more rarely, and 
then derived from elsewhere. In the thoracic organs the lungs may 
show sub-pleural petechiae, or more massive haemorrhages into the 
substance, especially at the base. In the heart there may be small 
haemorrhages beneath the pericardium and into the valves. Exten- 
sive extravasation may take place into the parotid gland, and Spencer 
suggests that the pressure thus exerted on the trunk of the facial 
nerve may be one of the causes of facial paralysis in the new^-born. 

Haemorrhage may occur also into muscles during delivery. Of 
these accidents the most important is hcematoma of the sternomastoid, 
since it is a cause of wry-neck which may last for months, and is, in 
some cases, possibly a large proportion, permanent. It is due, usu- 
ally, to great stretching of the muscle during delivery of the after- 
coming head. Less often it is caused by pressure of one blade of 
the forceps. It occurs also, occasionally, in vertex delivery. It is 
generally noticed first a few weeks after birth, when a small rounded 
or oval tumor is found in the muscle, generally in its upper part 
and on the right side. Sometimes, however, the first symptom which 
attracts attention is that the neck is not held straight. At a later 
stage the swelling is replaced by a sclerosis of the muscle, which is 
shortened and feels like a tendinous band under the skin. Petersen 
has suggested that in some, if not all cases, there is a congenital de- 
fect in the development of the sternomastoid, which is shorter than 
natural, and, therefore, more easily injured. This suggestion finds 
support in the observation that in many cases of congenital wry-neck 
the development of the whole of the face on the affected side is de- 
fective, so that it appears atrophied, as compared with the other. 

The skin of a healthy infant, twenty-four hours old, w^hen, that is 
to say, the congestion Avhich so frequently attends birth has passed 
off, is of an almost uniform deep pink or red color. This is due to 
hyperaemia, attended, perhaps, by some effusion of the coloring mat- 
ter of the blood. As a rule, the red coloration disappears in about 
a week, when the skin assumes the natural '' flesh tint," but in some 
cases the red color is succeeded by a distinct and almost universal 
yellow tint. To this condition is applied the term 

Icterus Neonatorum. — Since this occurs very frequently, and is 
commonly unattended by any other obvious departure from health, 
it has been thought by some to be physiological. It occurs, how- 
ever, more often among weakly children, those born prematurely, or 
in cases in which, during parturition the umbilical cord has been 
compressed or torn. It occurs also in association with exposure to 



ICTERUS NEOXATORUM. 39 

cokl, with atelectasis pulmoimiu, ami with imperfect establishment 
of respiratioD. It is met with more frequently in lying-in and 
foundliniT institutions than in private habitations. 

The pathology of icterus neonatorum has given rise to much con- 
trovei'sy. Fost-morfcm the serous membranes, the endocardium, the 
intima of the arteries, the liver, spleen, and kidneys, and the brain, 
have a yellow color which, according to Orth, is due to the presence 
of bilirubin. Uric acid infarcts Avhen present in the kidneys are 
deeply pigmented, and the urine contains yellow bodies, which Cruse 
has shown consist of bile pigments, either free or in epithelium cells 
or hyaline cylinders. In some cases a plug of mucus has been 
found in the ductus choledochus. All these facts point to the liver 
as the source of the pigment. On the other hand it is urged that 
since the fneces have the normal yellow or brow^n color, and as the 
urine does not contain much bile pigment, if any, and as the ductus 
choledochus is couimonly found patent after death, the icterus must be 
hsematogenous. In support of this theory is pointed out that during 
the first few days of extra-uterine life a great destruction of red 
blood-corpuscles takes place, by which much pigment is set free, 
while, at the same time, the metabolism of albumen is very active, 
so that great calls are made upon the functional activity of the liver. 
The most acceptable theory appears to be that the jaundice is due to 
a temporary hepatic insufficiency brought about in the manner indi- 
cated. This would produce a more marked effect if the ductus chole- 
dochus were blocked by a mucous plug, as it is in some, at least, of the 
fiital cases ; under such circumstances, the retention of color by the 
faeces must be attributed to the meconium remaining in the intestines. 

The characteristic symptom is the yellow tinge of the integuments, 
generally most marked on the face and chest, of the conjunctiva?, and 
of the gums, as can be made evident by pressing gently with the 
finger. The yellow tint begins to be noticeable about the second or 
third day of life ; if the skin still retains much red coloration, it may 
be brought out by pressure with the finger, the resulting patch of 
temporary anaemia having a yellow tinge. The child is not ill, 
suckles well, and the pulse is not slow. The urine is clear, generally 
of a light color, and contains a large quantity of urea and uric acid. 
The fieces are yellow or brown, and soft. 

The diagnosis must rest upon a general consideration of tlie circum- 
stiinces of tlie case, and especially on the time of the onset of the 
icterus. Congenital icterus points to a serious condition, to severe 
syphilis, or to congenital deficiency of the bile ducts, or occlusion of 
the ductus choledochus, or of the duodenum. The association of 
jaundice with uml)ilical inflammation is of serious significance. The 
occurrence f>f jaundice as a sym])tom of acute fatty degeneration, and 
with acute htemoglobinuria, will be mentioned later. 



40 DISEASES INCWEI^TAL TO BIRTH. 

The prognosis is good in uncomplicated icterus neonatorum^ though 
tlu' tact that a hirgo proportion of the children thus aifected are 
wi'aklv,an(l vcrv liable to suffer from gastric catarrh, must be borne 
in mind. 

The treatment should consist in keeping the child warm, giving it 
fresh air, and feeding it carefully and regularly with, if possible, its 
mother's milk. Mercurial and other laxative drugs should be avoided. 

Acute Fatty Degeneration of the New-Born is a rare and fatal 
form of disease observed in new-born infants. It is characterized by 
a parenchymatous inflammation of the viscera and of the skin, accom- 
panied by Inemorrhages and followed by fatty degeneration. 

The etiology of the disease is obscure ; it is probably an infective 
process, and may perhaps best be regarded as a form of septicaemia. 
In some cases there is obvious disease of the navel, which may then 
reasonably be regarded as the point of entry of the infection. The 
disease has been observed most often in infants which have been 
asphyxiated at birth, but is by no means confined to the weakly. 

The symptoms are progressive. In most cases respiration is never 
properly established, and the face, and to some extent the skin gen- 
erally, is cyanosed. The cyanosis, as a rule, deepens gradually, but 
in some eases suddenly, and eventually gives place to an icteric tint. 
The subcutaneous tissue may become oedematous. Ecchymoses may 
appear on the skin and mucous membranes, and haemorrhage may 
take j)lace from the navel. Vomiting is a common symptom and 
the rejected matter is blood-stained ; the stools contain blood, as does 
also the urine. The infant presently becomes collapsed, and death 
usually ensues in the first or, at latest, the second week. After death 
haemorrhages will be found to have taken place into the serous and 
mucous membranes, and there is fatty degeneration of the liver cells, 
the myocardium, the renal and pulmonary epithelium, and the intesti- 
nal villi. Haemorrhagic infarctions also may be found in the lungs, 
and haemorrhages into the stomach, intestines, and navel. 

The prognosis in a well-marked case in which the diagnosis can be 
definitely made is exceedingly bad. 

The diagnosis is often difficult, and in a case with a rapid course, 
especially if seen only shortly before or after death, it may be diffi- 
cult to exclude poisoning by phosphorus or arsenic except by chem- 
ical examination. The resemblance of the body after death to that 
of a child killed by suffocation, may be close, but the discovery of 
extensive fatty degeneration of the viscera will indicate the true cause 
of death. The possibility that the disease is septicemic in nature 
has been mentioned and when the navel is diseased it will be difiicult 
to exclude ordinary septicjemia from that source. 

The treatment can only be symptomatic. The partial asphyxia 
may be combated by artificial respiration, and probably the use of 



MASTITIS. 41 

oxygen might be of benetit. Ilivinorrliagos must bo controlled by 
ordinary means, and special attention should be given to feeding the 
iufant at regular intervals, giviug by pret'erence the mother's milk, 
which nuist be drawn otf if necessary. 

Acute Haemoglobinuria of the New-born ( Wiuckrrs Dimm-) 
is a rare and very serious general disease, probably of infective na- 
ture. It is characterized by cyanosis and liaMnoglobin;emia aud 
hi^moglobinuria. 

The disease attacks infants, who often appear to be robust, about 
the f«>urth day of life. The infant becomes restless and refuses food. 
The skin assumes a yellow or greenish tint, tlie respiration is hurried, 
but the pulse is not quickened nor the temperature raised. The 
urine, which is clear and of a brownish or olive-green color, contains 
epithelial cells, hyaline cylinders, masses of detritus and haemoglobin, 
but no bkxxl-cells. Vomiting and diarrluva are not infrecpient, and 
convidsions sometimes precede death, which is almost invariably the 
termination of this disease. 

The pathological conditions found after death point to the infective 
nature of the morlnd process. The kidneys are large and dark, with 
small ha'inorrhages in the cortex, and hiemoglobin infarcts in the 
pyramidal [wrtions. All the viscera are hypera^mic, and have a yel- 
lowish tinge, and all, but especially the serous membranes, show 
punctiform hfemorrhages. The spleen is large, firm, dark, and 
greasy on section. There is fatty degeneration of the liver and ex- 
tensive desquamation of the intestinal epithelimn, with swelling of 
Fever's patches. The blood is dark with a greenish tinge and con- 
tains an excess of white cells and red cells much altered, some nucle- 
ated and others degenerating. 

Mastitis. — In the healthy infimt of either sex the mammary glands 
on or about the fourth day of life l)egin to secrete a small quantity of 
fluid, which has the chemical and nn'croscoj)ic characters of milk, 
and contains colustrum corpuscles. The glands enlarge during the 
four or five following days, and then gradually decrease in size, until 
at the end of the third week, as a ride, they cease to be conspicuous, 
and the secretion is arrested. The enlarged mamma is a firm con- 
ical lx)dy, an inch or less in diameter, which is freely movable but a 
little tender. A drop of opalescent milk can be squeezed out as a 
rule, but usually the swelling is inconspicuous and passes imol)servcd. 
Occasionally the enlargement attains greater })ro|)ortions, one or l)otli 
glands l)ecome hard and very tender, and the overlying skin is red- 
dened ; in fact, a condition of mastitis is established which may run 
r»n to alxscess. 

The enlargement and functional activity of the mammjc in new- 
born infants is a physiological process, and it is very possible tiiat 
iie occurrence of mastitis neonatorum is to be attributed in most in- 



42 DISEASES INCIDENTAL TO BIRTH. 

stances to the superstition which leads a nurse to manipulate the 
jrlands rather violently to ^' break the nipple-strings/' or to draw off 
" the witehes' milk." The inflammation is associated with the pres- 
ence of pyogenic cocci, and may be attended by a good deal of 
fever, restlessness, and loss of appetite. Under suitable treatment it 
usuallv subsides without the formation of an abscess. When an ab- 
scess froms it almost invariably heals readily after incision, but in 
w(»aklv children may cause some trouble, and has been known to bur- 
row under the pectoralis, and to cause extensive sloughing of the 
skin. 

Treatment should be directed, in the first place, to the prevention 
of mastitis by protecting tiie glands from injury. When they be- 
come enlarged and tender they should be smeared with boracic oint- 
ment and covered with pads of cotton-wool bandaged lightly on. If 
their increased size, tenderness, and the redness of the skin indicate 
that inflammation is commencing, the ointment should be replaced by 
extract of belladonna and glycerine (equal parts). Hot fomentations 
or poultices may be used at once, or after failure of the belladonna. 
Not uncommonly a purulent fluid eventually exudes from the nipple, 
and the mastitis subsides without the necessity for incision. If 
fluctuation can be made out, it is best to make an incision radiating 
from the nipple, and as the segments of the gland are sometimes af- 
fected successively, it may be necessary to make more than one open- 
ing. 

The diagnosis is easy from the physical signs, but it is necessary 
to remember that some enlargement and tenderness of the glands is 
a ])hysiol()gical process. 

The prognosis is good, though in a marasmic infant the pain, rest- 
lessness, and fever attending mastitis may aggravate the condition 
seriously. Severe mastitis with abscess in infancy has been followed, 
in some cases, by imperfect development of the gland in girls at 
j)ub(*rty. 

Erysipelas Neonatorum. — The new-born infant is liable to suffer 
from erysipelas in two clinical forms -} (1) an acute general infection 
and (2) a creeping cutaneous affection spreading from some skin 
lesion. 

1. The (iciite general dimmc occurs, as a rule, in association with 
puerperal fever in the mother, or in institutions. The onset of the 
erysipelas is sudden, and is accompanied by severe general symp- 
toms, iii(rji temperature (105° F.), vomiting, diarrhoea, and jaundice, 
and is comj)licatcd frequently by pleurisy, peritonitis, and arthritis. 
Convulsions ensue, the infant passes into a condition of stupor, and 
life is seldom prolonged beyond the second day of illness. 

'See also Sclerema neonatorum, p. 48. 



ERYSIPELAS NEONATORUM. 43 

2. Creeping erysipelas starts from some lesion of the skin — IVoni 
the navel, the penis after cirennieision, or a pateh of intertrigo. It 
varies very greatly in severity, bnt is always a serions disorder. It 
is not always possible to traee infection from a previons ease, thongh 
the disease nseil to prevail as an epidemic in lying-in institutions 
before strict antiseptic precautions became the rule. It is now seen 
most often in the infants oi^ the ]wov living in insanitary surn)und- 
ings, and the victims are often fat and strong looking. In some 
cases the infection appeai-s to be conveyed by the nai)kins, and the 
area of aftected skin is sharply detined by the edges of these cloths. 
Once begun, the process tends to spread to the whole cutaneous sur- 
face, sometimes very rapidly, but more usually slowly, so that the 
parts earliest atfected are recovering while others arc being invaded. 
After the red color has faded from the skin, a good deal of soft 
oedema may remain. In the loose ]>arts, as, for instance, the scrotum, 
the swelling may be very great. ^lore or less extensive areas may 
become the seat of phlegmonous inflammation, and abscesses may 
form, or necrosis of skin may occur. The general symptoms vary a 
good deal in severity. There is, usually, continuous fever, with 
morning remissions, but in the more chronic cases, especially in 
weakly infants, the temperature may be little above the normal, and 
may even be sub-normal in the morning. The appetite is sometimes 
retained. The pulse becomes small, rapid, and weak. The disease 
may be complicated by diarrhoea and vomiting, by pneumonia, or by 
])eritonitis. The advancing border of cutaneous infiltration is gen- 
erally very regular and well-defined, and upon the inflamed skin are 
seated, in many cases, small vesicles containing a clear white or 
yellowish fluid. The prognosis is bad, although recovery sometimes 
takes place in the less acute cases. Treatment exercises little influence 
on the course of the malady. The infant should be fed with its 
raoth(*r's milk in small quantities at short intervals, and alcoholic 
stimulants prescribed, a teaspoonful of good claret or champagne, or 
ten drops of brandy in water every two hours. The internal ad- 
ministration of })erchloride of iron is well borne, and may be of ser- 
vice (liquor ferri perchloridi, TTL ij-iv, every two hours alternately 
with the stimulant). An attempt may be made to check the sjiread 
by painting the edge with absolute alcohol or with silver nitrate 
(mitigated stir-k, or a solution gr. xx to ."^)j). 

The diagnosis is not difficult as a rule. In the less acute cases, in 
which hesitation is most likely to Ix; felt, the degree of cutaneous in- 
filtration, the well-defined regular slowly-sj)reading edge, the fever, 
and the general depression usually leave little doubt as to the nature 
of the disease. In syphilitic infants the skin affcrtion about the but- 
tock may, when it is beginning, be attended by extensive redness and 
infiltration of the skin, corresponding more or less closely with the 



44 DISEASES INCIDENTAL TO BIRTH. 

area covorod by the napkin, but this is seldom seen during the first 
two weeks of Hie. The eondition with which creeping erysipelas is 
most liable to be confounded is 

Erythema Neonatorum. — This is a mild affection, though the 
ervllieina mav be exceedingly widespread. It makes its appearance 
usual Iv about the second or third day of life, and spreads rapidly 
over tlie greater part of the trunk and limbs. The skin is red, full, 
and a little tense. The infant is restless, and loses appetite, but the 
temperature is little, if at all, raised. After a day or two the ery- 
thema begins to fade, and there is usually a little fine desquamation. 
The diagnosis from erysipelas and scarlet fever must be made from a 
careful examination of the characters of the rash, the mild nature of 
the general symptoms, and the absence of sore throat, or much fur- 
ring of the tongue. The treatment should consist merely in keeping 
the parts powdered, and in the use of lukewarm baths, which di- 
minish the restlessness. 

Diseases of the Navel. — The umbilical cord usually separates 
spontaneously about the fifth day without giving rise to any trouble, 
but occasionally the navel becomes the seat of inflammatory or other 
morbid processes, of which the most common is 

Ui.cp:ratiox. — After the separation of the cord, a small granu- 
lating discharging surface is left, which often becomes covered with 
a crust. In some cases the granulations are so exuberant that they 
form a small tumor of irregular shape, which projects from the navel. 
To this condition the term fungus umbiUcalis has been applied. This 
granuloma has a smooth moist surface which bleeds easily, and the 
puriform discharge from it irritates the surrounding skin, which be- 
comes red and excoriated. The treatment of umbilical ulceration 
should consist in antiseptic applications — boric acid lotion followed 
l)y the application of boric ointment, or mild white precipitate oint- 
ment, and the use of an antiseptic dusting-powder. Fungating 
granulations should be touched with lunar caustic stick, and dressed 
with one of the ointments already mentioned. Neither condition is 
in itself of any serious consequence, but they draw importance from 
tlie fact that the ulcerated surface may serve as the point of entrance 
of erysipelatous or other infection. 

Phlegmonous Inflammation of the cutaneous structures about 
the navel may ensue upon ulceration, or after the normal detachment 
of the cord. A conical, red, tender swelling like a huge boil, with 
the navel more or less everted at its centre, forms, and suppuration 
generally ensues, the resulting abscess, if not incised, opening either 
at the navel or in its neighborhood. Sometimes the pus tracks down- 
wards, and eventually a long sinus fi)rms which may reach to the 
pul)es and prove very troublesome. The patient during the attack 
suffers from pain, restlessness, want of appetite, and slight fever. 



AFFECTIOXS OF THE XAVEL. 45 

If a sinus form the infant becomes much exhausted bv the discharge, 
which is often copious, and may sutfer much from dermatitis set up 
bv it. In the trcatincnf these risks must be borne in mind, and if 
poultices, or hot fomentations, with, perhaps, the addition of belhi- 
donna and glycerine, fail to arrest the intiammation, an incision 
should be made near the umbilicus as soon as Huetuation can be made 
out, the abscess cavity thoroughly drained, and all discharires taken 
up by a pad of absorbent cotton-wool frequently renewed, an anti- 
septic ointment being applied to the surrounding skin. A possible 
but, happily, nire complication of phlegmonous inflammation of the 
navel is (janffrcnv of the skin over the inflamed area. The whole 
thickness of the abdominal walls may be involved, laying bare the 
peritoneum, or producing an opening into the peritoneal cavity, 
through which the intestines, glued together by inflammation, are 
visible. Crangrene is attended by extensive surrounding inflamma- 
tion and o?dema of the skin, by fever, and by rapid loss of strength. 
The freafmeut should consist in careful systematic feeding and the 
use of stimulants ; locally, hot antiseptic fomentations should be used, 
to enctmrage the separation of the sphacelus ; and, later, antiseptic 
powders or iodoform may be freely dusted on, the wound being thor- 
oughly irrigated every three or four hours with boric-acid solution, 
and again dusted with iodoform. 

Thrombosis of the umbilical vessels is another complica- 
tion of ulceration of the navel. The arteries are affected more often 
than the vein. The infective agent is usually the streptococcus pyo- 
genes. Past mortcin the affected arteries are hard and thick, of a 
bn>wnish color, and surrounded by gelatinous cedematous tissue ; 
they contain, according to the age of the arteritis, a soft reddish 
thrombus, or puriform material produced by its breaking down. 
The coats of the vessels are infiltrated and may eventually give way. 
When there is phlebitis the vein is filled with breaking down throm- 
bus, its walls are infiltrated, and the surrounding tissue wdematous. 
The ulceration of the navel may liave healed. Evidences of embol- 
ism may be found in many of the internal organs — the brain, spinal 

rd, lungs, kidneys, liver, spleen. Pneumonia, purulent pleurisy, 
and joint affections are not uncommon ; in flict, every lesion of acute 
pyaemia may be met with. 

The general si/mpfoins are not very characteristic. The infant be- 
comes restless, refuses the breast, is feverish, and soon becomes 
jaundiced. It lies upon its back, with the knees drawn up, and it 
may Ix^ possible to feel the two thrombosed arteries as hard cords 
running down from the und>ilicus on either side of the linea allja ; 
if there be phlebitis there will V>e some swelling and tenderness in 
the middle line above the umbilicus. The pro(/noi<i.H is very bad, 
especially in premature children, and death frequently ensues in a 



U> DISEASES JNCWENTAL TO BIRTH. 

{v\\ (Invs. In otlior cases the infant may survive for three weeks or 
more, cviihMU'c of the pyemic infection of various organs being 
atVordcd from time to time. For the prevention of this very fatal 
disease we must look to antiseptic treatment of the navel, and to the 
separation of new-born infants from persons suffering from erysipelas 
or puerperal fever. The treatment is unsatisfactory, since direct ap- 
])li('ations to the thrombosed vessels appear to be impossible. If 
anv indication for surgical interference is afforded it ought to be 
followed without delay, as a chief danger is the occurrence of septic 
embolism. The restlessness by which the infant's strength is ex- 
liausted may be relieved by warm baths or by warm packs, and in 
addition to regular feeding with its mother's milk, wine or brandy 
may be given, and the effect of quinine tried in increasing doses. 

HAEMORRHAGE FROM THE UMBILICUS may come, (1) from the 
arteries, owing to injury during birth, or to the cord being insuf- 
ficiently secured, or, at a later date, owing to gangrene of the cord 
before the vessels have become occluded. In weakly infants, in 
whom the pulmonary circulation has been imperfectly established, 
a considerable amount of blood may be lost in this way, but the 
hnemorrhage is, as a rule, easily checked by a pad of cotton-wool, or 
by applying a fresh ligature to the cord, though the accident is most 
likely to occur when the first has been applied too near the navel. 
Haemorrhage after gangrene of the cord must usually be treated by 
ligature over pins. (2) The bleeding may be an oozing from the 
navel, after the separation of the cord, and may be an indication of 
a general disease, haemophilia, syphilis, septicgemia, or acute fatty 
degeneration. The bleeding begins usually about the fifth day of 
life, and before the cord has separated completely. It is not arrested 
by compression and there are simultaneous hsemorrhages into the in- 
ternal organs, and into the skin. The prognosis, owing to the fact 
that the bleeding depends upon a general condition, is bad, and life 
is seldom prolonged for more than a few days. [We must, how- 
ever, distinguish between umbilical haemorrhages due to these general 
causes, and those of an infectious origin occurring as a manifestation 
of the disease known as the HwmorrhagiG Disease of the New-horn, 
described more fully below.] This form of umbilical hsemorrhage 
is rare, and the treatment is unsatisfactory. Styptics should be used, 
and AVright's physiological styptic^ suggests itself as well adapted 
to the purpose. If these fail, the navel must be ligatured with a 
thread eai-ried round it on a needle. The child must be kept quiet, 
^i'(\ carefully, and the general condition treated. 

Tetanus Neonatorum is the same disease, due to the same infec- 
tive agent — the tetanus bacillus — as that which occurs in adults. 
The chief peculiarity is that, as a rule, it at first affects the muscles 
^Lancet, 1883, i., p. 485. 



TETAyUS NEONATORUM. 47 

of the jaws ami face, and has hence been known as trisnins neona- 
torum. 

Etiology. — The infection finds entrance by the navel, and negligent 
or dirty methods of treating the cord are the chief contributory causes. 
The disease has prevailed as an endemic in certain localities (Faroe 
Islands), and in institutions, and want of ventihition has appeared 
to be a determining cause in such circumstances. Ex})osure to cold 
and the use of too hot baths have also been considered to be among 
the remote causes. In some instances the infection appears to have 
been carried by midwives. 

The symptoms begin usually between the fifth and the ninth days 
of life, and the first thing to attract attention is that the infimt has 
difficulty in suckling, and that the attemjit is accompanied by con- 
traction of the masseters and the orbicularis oris. These muscles 
are found to be hard to the touch. The infant is restless, cries much, 
and frequently wakes from sleep with a cry. The muscular cramps 
are brought on by any movement ; they involve gradually a larger 
number of muscles, and finally the attacks come on without obvious 
cause. The brows are wrinkled, the eyes closed, the face drawn, the 
alie nasi dilated. Xext the head and neck become stiff in each attack, 
and in the intervals relaxation is incomplete. The tonic contractions 
finally involve the trunk muscles, and in the attacks there is well- 
marked, often extreme opisthotonos, the abdomen is hard, the hands 
clenched, the legs abducted. During the attacks res])irati<)n is ar- 
rested and the surface becomes cyanosed ; in the intervals it is shal- 
low and irregular. The pulse is fast and thready. The temperature 
may be little raised at any |)eriod of the disease ; on the other hand, 
it may mount gradually from the beginning until it attains 104° or 
105° F. shortly before deatli, or it may be high from the first. The 
urine contains albumen and casts. The usual termination is in death, 
which may occur within twenty-four hours, though life may be pro- 
longed for a week or ten days. 

The prognosis is extremely unfavorable. A low temperature is of 
gfKxl augury, and the first signs of improvement are a lengthening 
of the interval between the attacks and more complete relaxation. 
Improvement in any case is very gradual, and recover}' can only be 
looked for if the infant has a considerable reserve of strength. 
Treatment has littk' effect in the more acute cases, l)ut in the less 
severe, advantage may l^e hoped from the systematic use of chloral 
hydrate (| to 1 gr. every hour). If swallowing is impossible, the 
remedy must l>e given by enema fgr. H ). Momentary relief <luring 
the attacks may be ol)tained from inhah'itifMis of chlorofi»rm. \\'ith 
the chloral may be combined potassium bromide, 15 to 20 grains 
being given in the course of the day. Sulphonal (gr. j-ij) every 
three or four hours bv enema has also l)een recommendcHl, and extract 



4S DISEASES INCIDENTAL TO BIRTH. 

ofcalahar Www administered by hypodermic iajection (gr. J dissolved 
ill 111 x ot* wator) has given good results in some hands. The infant 
shouUl he kept very quiet in a shaded room. Its food should consist 
of its mother's milk and should be given regularly, as the main hope 
of recovery, even in the least severe cases, is in maintaining sufficient 
stivni!:th to enable the infant to outlive the disease. Rectal alimen- 
tation is recommended, but in some cases feeding with the nasal tube 
seems to atibrd promise of better results. If the navel be ulcerated 
or otherwise inflamed, it should be thoroughly treated with antisep- 
tics. The use of tetanus antitoxin has not been followed by constant 
or obviously beneficial results, but it does not seem to be attended by 
anv inconvouienccs, and may therefore properly be resorted to. 

Sclerema Neonatorum is a rare disease characterized by a pe- 
culiar hardening of the cutaneous structures. It begins usually in 
the calves, but sometimes in the cheeks, during the first week of 
life. The subjects are usually premature or weakly, and the ma- 
jority of cases have been observed in institutions, but beyond these 
facts nothing is known as to the etiology of the disease. The morbid 
anatomy does not throw much light on the pathology. There is an 
overgrowth of the connective tissue of the skin and subcutaneous 
layer, with an absorption of fat, and a marked dryness. The viscera 
show no morbid changes beyond pulmonary collapse, which is more 
probably a consequence than a cause of the sclerema. 

The symptoms are characteristic, for the peculiar hardness of the 
skin n^sembles no other condition. It does not pit on pressure, and 
feels like leather or wood ; the smaller folds are obliterated, the 
larger strongly marked with firm edges. Its color is at first whitish 
or marbled, but later there is a yellow tinge. The induration 
spreads with varying rapidity, and may eventually involve almost 
the whole skin, so that the infant lies in a condition resembling H^/or 
viortis, the only movement perceptible being respiration ; if lifted up 
it remains rigid, like a wooden doll. Rigidity of the lips and cheeks 
renders suckling difficult or impossible. Respiration becomes shallow 
and irregular, the pulse if it can be felt, which is often not possible 
owing to the hardening of the skin, is small, and the heart-sounds 
weak. There is constipation, and very little urine is passed. The 
temperature falls below normal, even to 85° F. or lower, and the 
mouth feels cold to the finger introduced into it. Death is due to pro- 
gressive exhaustion, or not infrequently to intercurrent pneumonia. 

The prognosis is very bad in all cases in which the disease has 
become extensive, but there is a condition which resembles sclerema, 
and is generally assumed to be identical, which is not very serious. 
It is generally confined to the buttocks, groins, and front of the ab- 
domen, covering an area coinciding with that enveloped by the nap- 
kins. The skin becomes hard, solid, and does not pit on pressure ; 



(EDEMA NEOXATORUM, 49 

the folds of the iiatos are olosoly opposed, and there may be difficulty 
in extending the thighs. The skin is not white or yellow but of ji 
deep red, like raw ham ; firm pressure with the linger produces little 
alteration in the color. The surface is glazed and dry. Sometimes 
a few other similar but smaller patches may be found on the arms or 
calves. In these cases the general health does not suffer, and after 
a week or two the thickening and redness begin to fade and ilnally 
tlisappear. Whether this condition, which, after developing rapidly 
in a few days, remains localized until its recession, should be re- 
garded as pathologically identical with sclerema, is doubtful. Barrs, 
who has given a good description of a case/ holds that it should, 
and that true sclerema sometimes begins in this way. Clinically, at 
least, the two conditions differ in appearance and result. True 
sclerema is rare, but this local condition is not uncommon. 

The diagnosis of sclerema, if the local condition just mentioned be 
excluded, is not difficult. It is distinguished from (edema neonato- 
rum, with which it has been confused, by the absence of pitting and 
by the color of the skin. At the same time, it must be remembered 
that sclerema has, in a few cases, been preceded by some anlema. 
The history of the case, and a careful observation of the cause of the 
rigidity, ought to prevent any confusion with tetanus, and some help 
may be obtained from the temperature, which in tetanus, if not 
raised, is seldom below the normal as in sclerema. 

The treatment of sclerema, owing to the absence of any certain 
knowledge as to its pathology, must be symptomatic. An attempt 
should be made to maintain the body temperature by placing the 
child in an incubator or " artificial nurse,'' if one be at hand, or by 
wrapping the body in cotton-wool and applying artificial warmth ])y 
means of hot lx)ttles or sand bags under blankets in a bed. Stimu- 
lants — wine, brandy, ammonia, musk, camphor — should be given, 
and food, preferably the mother's milk, at regular intervals, in a 

(Edema Neonatorum is not a disease but a symptom of various 
pathological conditions similar to those which produce rrdema at 
other ages — heart disease (foetal endocarditis) and nephritis. It oc- 
curs also in marasmic infants, especially in those affected by pulmo- 
nary atelectasis, and occasionally in congenital syphilis. It is some- 
times a sequel of erysipelas, and occasionally ])recedes sclerema. 

The symptoms present a general rescmljlance to sclerenui, and the 
dema may even be so tense and widespread as to interfere with 
movement. The skin is pale or marbled, and always ])its on ])res- 
sure. The redema begins in the lower extremities, and gradually 
a.scends ; when it reaches the genital organs it often j^roduees extreme 
distension and deformity. The general condition of the infrmf is 

' Brit. Med. Journ., vol. i., 1889, p. 994. 
4 



50 DISEASES INCIDENTAL TO BIRTH. 



^ 



usuallv one of grciit depression, and the temperature may be far be- 
low normal. The distinction between this condition and sclerema 
has already been indicated, and the treatment must depend upon a 
recognition of the pathological condition upon which the oedema is 
do])ondcnt. 

Melaena Neonatorum (gastro-intestinal haemorrhage) is a symptom 
of various morbid conditions of the gastro-intestinal mucous mem- 
brane. The most frequent of these is congestion due to asphyxia at 
birth, to pulmonary collapse, or heart-deformity. Asphyxia appears 
to be the condition most often determining melrena, and it has been 
shown, by experiments on animals, that it can produce extravasation 
into the gastric mucous membrane. Among other conditions the 
most common is ulceration of the oesophagus, stomach, or intestines. 
This has been attributed in some cases to venous stasis caused by 
asphyxia at birth followed by thrombosis ; in others to destruction 
of follicles ; in others to fatty degeneration of the arterioles. In 
others the cause has been sought in emboli derived from the ductus 
arteriosus, or from the umbilical vein. Extravasation beneath the 
gastric mucous membrane with subsequent rupture into the stomach 
lias been observed, and in a few cases there seems to have been reason 
to attribute the bleeding to the hsemorrhagic idathesis. Septicsemic 
diseases must also be mentioned as occasional causes of melsena. 

The symptoms are, as a rule, very pronounced. An infant, born 
to all appearahoe healthy, becomes without obvious cause blanched, 
collapsed, and somnolent. Sometimes the first symptom is vomiting 
of blood or blood-stained matter ; in either case altered blood is soon 
passed from the intestine. The blood may be tarry, or clotted, and 
comparatively little altered in color. In other cases, when the bleed- 
'.ng is less rapid, the condition of anaemia and collapse is more slowly 
established. The bleeding may begin at any time within the first 
week or ten days of life, but most commonly on the second day. If 
copious, convulsions may occur, and the infant rapidly succumbs, 
death being preceded by extreme blanching of the surface, subnormal 
temperature, and stupor. 

The prognosis in cases in which the symptoms become pronounced 
is grave. The mortality is probably about 60 per cent. But small 
hemorrhages may occur into the intestinal canal, producing marked 
blackening of the faeces without serious consequences. Moreover, it 
should be remembered that the stools, or more often the vomited 
matter, may l)e stained with blood derived from the nose or naso- 
pharynx, or from cracks about the mother's nipple, which sometimes 
bleeds very easily. 

If no local sr>urce for the blood can be found, the treatment should 
consist in the administration of cold liquid food (whey, predigested 
milk, iced broth) ; of the application of cold to the abdomen (ice-bag 



PEMPHIGUS yEOyATORUM. 51 

or ice-cloths) ami warmth to the extremities; ami of the internal 
administration of stypties — uallie acid (gr. j every three honrs), oil 
of tnrpentine (lUj in mneihige, every honr), ergotine (gr. } to A every 
two honrs). Extract of krameria (gr. ij every two or three honrs) 
by the month, and injections of infnsion of krameria (.^iv to v) into 
the bowel are rect)mmended by Dr. Enstaee Smith. C'alcinm chloriih' 
might probably be of service by increasing the coagidability of the 
blood. 

Pemphigus Neonatorum occnrs in two forms ; syphilitic infantile 
{>emphigns (^<j. r.) and a form which occnrs under bail sanitary condi- 
tions, either sporadically in jirivate honses, or endemieally in lying- 
in institutions. The infant is well nourished, and the bulhe, which 
are numerous, appear a few days after birth on the pubes, thighs, 
buttocks, or around the mouth and chin — not on the hands or feet, 
which are the usual sites of syphilitic pemphigus. The infant should 
be removed to a healthy house, and if this be done will usually re- 
cover rapidly under the use of mild antiseptic applications. 

[Several conditions in the new-born predispose to hiT?morrhage, 
. 7., delicacy of the blood-vessels, change in the circulation at birth. 
These hfemorrhages may be considered under two heads: (1) acci- 
dental or traimiatic hiemorrhages, chiefly incidental to birth and (2) 
spontaneous haemorrhages. The first group has been duly consid- 
ered above, and also some of the second group, as separate diseases. 
But it would seem better to class these latter under one head, and 
to regard them with other spontaneous luemorrhages, merely as 
symptoms of the infectious disease now generally known as llivmor- 
rhar/ic Disease of the Xeic-boni. This class of htemorrhages occurs 
within the fii*st few days of life ; is spontaneous in origin, nudtiple 
in its location, occurring most often in the gastro-intestinal tract, 
navel, skin, and mouth, and is self-limited, running its course to 
death or recovery. While undoubtedly infectious in its nature, its 
exact cause is still unknown, bacteriological investigation not yet 
being conclusive. 

It is of esix-cial importance that the malady be distinguished 
from true haemophilia, on account of the more favorable prognosis 
in the former ; for we should not approach such cases with the idea 
that they may recover from this particular attack of bleeding only 
to die later from a slight cut. The main j)oints in thediffenntiation 
of the Hiemorrhagic Disease of the New-born from h;emopiiilia are 
as follows: the rare occurrence of hiemophilia before the second 
year of life, with absence of a family history of bleeding, the f>ccur- 
rence of the Hiemorrhagic Disease nearly eipially in Uith sexes, with 
elevated temperature, a self-limited e(>urse, and absence of recurrence. 

Townsend gives a careful study of this (li-<.i-«' In tlic Anliivrs of 
Pediatries, Vol. XI., No. 8.] 



CHAPTER IV. 
FOOD. 

The Stomach and Intesthies at Birth — Milk — Physiology of Digestion — The Quantity 
of Milk taken at Various Ages — Kate of Increase in Weight — [Management of 
Brea.st Feeding] — Artificial Feeding of Infants — Fresh Cow's Milk — Condensed 
Milk— Infant's Foods— The Bottle— Effects of Boiling— Bacteriology of Milk- 
Sterilization — Pasteurization — Milk Laboratories — [Modification of Cow's Milk 
— Indications for Modifying — Diet in Second Year]. 

The stomach of the infant at birth lies between the liver in front and 
the spleen, left adrenal, kidney, and pancreas behind. As the infant 
grows the fundus enlarges more rapidly than the rest of the organ, 
but, throughout early childhood at least, the normal position of the 
lesser curvature is vertical. At birth its capacity is about oj or Sjss ; 
at three mouths Siijss to Siv ; after this age the rate of increase is 
slower, so that at the age of one year its capacity is about Six. The 
rate of increase in the capacity of the stomach corresponds, therefore, 
fairly well with the rate of increase in the weight of the body. 

At birth the length of the small intestine (9 ft. 5 in.) is about five 
times that of the large (1 ft. 10 in.) which is about the height of the 
body. During the first two months the growth of the small intestine 
is rapid, the increase being 4 feet.^ At birth the sigmoid flexure 
forms nearly half the length of the large intestine, and one or more 
loops curve down into the pelvis. During the first three or four 
mouths the colon grows more rapidly than the sigmoid, which ceases to 
curve so far into the pelvis.^ The caecum in infants and young children 
often lies higher and more towards the middle line than in the adult. 

Freshly drawn milk consists of a fluid part, the milk plasma, and 
of solid particles evenly disseminated through it. The solid particles 
are minute oil globules, probably coated with proteid, a varying num- 
ber of small colorless cells without fat, and particles of casein and 
nuclein susi)ended in the fluid. Human milk is alkaline ; that of 
cows, when quite fresli, either alkaline or amphoteric, though it is 
acid when it reaches the consumer. The quantity of milk secreted 
by a healthy woman varies very much, but, on the average, may be 
set down at a pint and a quarter to a pint and three-quarters in 

' The figures are those given by Treves, Brit. Med. Journ., 1885, i., p. 415. 
'^.See Anatomical Constipation, p. 440. 

52 



THE STOMACH. 



53 



twenty-four hours. The ehief proteid eonstituents of milk are ease- 
inogen and laetalbumen. The former is the preeursor of easein, 
which is formed from it bv the action of rennet, a ferment secivtcd 
treely by the stomachs of sucklings. At the same time some ^ * whey- 
proteid " is formed and remains in -solution. This curdling does not 
take place except in the presence of calcium salts (phosphate and 

Fig. 2. 




\ 



nia^rram to illustrate thecapacitr of an infant's stomach. A, The smallest outline represents 
'- stomach of an infant, age 5 days (c-apacity 25 cc; less than 1 fl. or..). ». The intermediate 
It line repiesents the stomach of an infant, ape Vl months (eapacity riO cc; al>out 4 fl. oz.). C, 
!ie dotted oatline represents the dilated stomach of a rickety infant, age 7 months (capacity 300 
.; aboat 10 fl. or.). (All X %■) Afler ROTCil (K'entinp'n r,/rtoptr,ii,i). 

Uloride) which, however, are natural constituents of milk. In 
human milk the curd .separates out in fine flocculi. Laetalbumen 
olosely resembles serum all)umen. It is slowly coagulated at tem- 
jHratures l>etween 70° and S0° C. (in cow's milk at 77° C. accord- 
ing to Halliburton). Milk is the product of the functional activity 
of the epithelium of the acini of the mammary gland, wliicli in the 
active state of the gland are continually undergoing fatty change and 
disintegration, liln'rating the fiU glo!)ules which float in the clear 
liquid secreted from the lymph. J^ictose, or milk sugjir, has only a 



54 FOOD. 

slijxhtly sweet tasto and is less soluble than sugar or dextrose. It 
readilv underooes tlie lactic-aeid fermentation, and the lactic acid 
may subse([uently be transformed into butyric acid. The chief salts 
of human milk are chlorides and phosphates of potassium, sodium, 
and calcium. The percentage composition of human milk shows 
slight individual variations, and is not constant in the same woman 
at all times, but the following may be taken to be a fair average : 



Water. 


Proteid. 


Fat. 


Sugar. 


Ash. 


87.7 


1.82 


3.94 


6.23 


0.31 



The most important characteristics of human milk, and those by 
M-liioh it differs most from that of the cow^ are the low proportion of 
proteids and the high proportion of milk sugar. Franz Hofmann 
from the result of the recent series of analyses^ made by him puts the 
j)ercentage of jiroteid as low as 1.03. 

Digestion of Milk. — The milk obtained by sucking is swallowed 
at once, and as the saliva and other secretions of the mouth are 
scanty, it reaches the stomach practically unaltered. The watery 
gastric secretion contains two ferments — rennet and pepsin — hydro- 
chloric acid and mucus. \Yithin a few minutes the rennet produces 
white fiocculi of casein, in which much fat is entangled. The al- 
bumens of the milk are peptonized by the action of the pepsin and 
hydrochloric ac^.id ; while, owing to the continuous secretion of the 
acid gastric juice, and perhaps to the conversion of a part of the 
milk-sugar into lactic acid, the acidity of the gastric contents in- 
creases progressively during digestion. When farinaceous foods are 
taken the increase is less rapid. The passage of the partially di- 
gested milk from the stomach into the duodenum begins early, and 
is completed in from one hour and a half to two hours after the 
suckling. AVhen the food consists of cow's milk the time is longer. 
Intestinal digestion is estimated to last from six to eight hours. In 
the duodenum and the upper part of the jejunum admixture with the 
bile and pancreatic juice takes place, a bright yello^v smooth pap 
being thus formed, and much of the fluid is absorbed. As the ma- 
terial i)asses along the intestine, digestion and absorption proceed, 
its bulk is reduced, and it becomes again more fluid, owing partly to 
solution of casein, and partly to the addition of the intestinal secre- 
tion. In the ciecum, by the gradual absorption of water and the 
additi(>n of mucus, the orange-yello^v, thick, pappy fseces, character- 
istic of normal digestion in the infant, are produced. The most 
importiint part of the intestinal digestion takes place in the small 
intestine, and especially in its upper part, although the absorption 
of fat still goes on in the colon. The fseces are acid, as indeed are 
the intestinjd contents throughout. 

' Made for Ileubner (Pcnzoldt and Stintzing's ''Handbuch," Bd. iv., s. 178). 



DIGESTION OF MILK. 55 

In the healthy infant the digestion oi' milk is very complete. 
Chemieal examination of the faves slunvs that the whole of the sngar, 
nearly all, or more }n"obal)ly all the albnmen, 9G to 98 per cent, of 
the fat, and nearly all the water (and presumably the salts) of the 
milk are absorbed. A considerable part, about a fourth, of the 
solid, dry contents of the fteces consists of fats — neutral fats, fatty 
acids, and soaps. ^ 

The due performance of digestion depends upon the perfection of 
the two processes of secretion of the digestive fluids and the absorp- 
tion of the products of digestion. Absorption is not merely a mechan- 
ical process due to osmosis and differcnces\)f pressure, but is brought 
about, in part, by the vital activity of the intestinal epithelium. 
The pancreatic secretion is essential to the due absorption of fat. It 
acts, apparently, by splitting up a part, probably a small part, of the 
neutral fats ; the fatty acids thus produced form soda-soaps which 
facilitate emulsion, and the intestinal cells subsecpiently take up the 
line emulsified particles. The absorption of fat by the epithelial 
cells takes place mainly in the upper part of the small intestine ; it 
begins immediately after the entrance of the bile and pancreatic 
juice, and is continued throughout the jejunum. It is slow, occupy- 
ing probably six to seven hours, but, in health, very complete, the 
faeces containing, as has been said, only from 2 to 4 per cent, of the 
fat taken. - 

In a healthy infant the motions, [)assed usually thrice a day, are 
soft, homogeneous, of the consistency of cream or rather thicker, but 
not formed. Their color is bright orange or golden yellow. The 
odor is not of pronounced faecal character, is, in fact, rather charac- 
teristic, and indescribable, never putrid. The passage of flatus with 
the stools is not the rule, but eructations, probably of air swallowed 
with the milk, are common after suckling. To this cause, also, at- 
tacks of hiccup, to which infants are very subject, may, with proba- 
bility be attributed. They end sometimes in vomiting, which occurs 
very readily in infants. In many instances this rejection of milk 
must be accounted a physiological process, the stomach merely ex- 
pelling some excess by which it has been over-distended. This 
expulsion of a part of the contents of the stomach is clearly unat- 
tended by nausea or pain, and the term rrf/nrf/ifdfion may, witli 
advantage be apjilied to it. It is, indeed, a common saying that a 
"sick baby " is a healthy one. 

The quantity of milk taken daily by a healthy infant at the breast 

'O. Heubner in Penzoldt and Stintzing's " Handbuch d. Spec. Tberap.," IM. iv., 
8. 165. 

«In Vaujfhan Ilark-y's experiments on dogs {.lonm. of P/ii/h., xviii., p. 1), the 
profK)rtion absorbed eventually amoiintetl to Ho per cent,, but the animals had pre- 
vioa-'lv undergone a prolonged fast, which diminishes the power of forming the nor- 
mal digestive secretions. 



r^G FOOD. 

increases with its age. There are considerable variations in indi- 

vi(hi'al cases, bnt, adopting the estimate of Heubner/ we may take as 

averages : 

Under 1 month 350 grammes, or about '^xj. 
2 to 8 months 800 " " " ^xxviij. 

Over 3 " 1,000 " '' " ^xxxv. 

A litre (1,000 g. ) of human milk, according to the analyses of F. Hofmann, adopted 
by lleubner (Penzoldt and Stintzing's "Handbuch," Bd. iv., s. 178), contains 





Proteid. 


Fat. 


Milk-sugar. 


Salts. 


grammes 


10.3 


40.7 


70.3 


2.1 


grains 


159 


628 


1,085 


32 



I 



or, in round numbers, two and a half ounces of milk-sugar, one and a half of fat, and 
one-third of an ounce of proteid. 

During the first two or three days of life, before the secretion of 
milk is fully established, and for some days longer, the healthy in- 
fant is irregular in the frequency with which it suckles, but by the 
second week it becomes exceedingly regular. As a rule, it will 
suckle six, or at most seven times in the twenty-four hours, and at 
each suckling empties one breast. It will sleep seven to nine hours 
at night, so that roughly it suckles about every three hours during 
the day — e. g., at 6 a.m., 9 a.m., noon, 3 p.m., 6 p.m., and 9 p.m. 
Some infants do well if suckled at both breasts at each meal, with a 
longer interval between the meals. But if an infant suckle at both 
breasts at each meal, with an interval of only two or three hours be- 
tween the meals, it is an indication that the yield of milk is becom- 
ing inadequate either in quantity or quality. Before coming to this 
conclusion it is necessary to make sure that the infant is not suifer- 
ing merely from thirst, either physiological or due to stomatitis, or 
from dys])epsia, which may lead it to desire to suckle frequently in 
the expectation of relieving the gastric discomfort which it experi- 
ences. 

[In some instances, however, good results have apparently at- 
tended the adoption of this habit of giving both breasts every two or 
three hours. When the yield is insufficient the breasts from the 
more frecjuent stimulatioji are excited to greater activity and will 
grachially secrete a milk also richer in quality. It is possible in this 
way to convert a poor into a good breast-milk.] 

The knr/th of time for which it is customary to suckle an infant 
varies in different countries. In Germany, from nine to twelve 
months appears to be the rule ; in France and, probably, in Eng- 
land, the average is about twelve mouths or rather longer ; in Ire- 
land, eighteen months or more ; and among negro races even longer. 

' Conf. Feer {Jahrb. f. Kinderfilde, Bd. xlii., s. 195), who gives a series of interest- 
ing tables. 



DlGESTIOy OF MILK. 57 

If the mother become preiiiiant, she shouUl cease to suckle her in- 
fant. The occurrence of menstruation leads, as a rule, to a (liminu- 
tion in the quantity and to a deterioration in the (juality of the milk ; 
the infant loses weight and often suffers from diarrhcea, but this may 
be only a temporary disturbance. If menstruation have aj^peared 
early in the period of suckliuir, and if any loss of health wiiich the 
infant may have shown is quickly rciiiiined it will usually be ad- 
visable to await a fresh ajipcarancc of the menses, which may be 
long delayed, or distinct evidences of pregnancy, before weaning. 
On the other hand, if the infant have been suckled already for nine 
or ten months it will usually be advisable to wean it. After nine 
months a healthy infant begins to desire other food, and has no 
difficulty in digesting well-cooked oatmeal and other cereal Hours. 
At about one year it can take bread, fruit, meat, and fish in small 
quantities without disadvantage. In this, which is the natural mode 
of weaning, the infant is accustomed gradually to a mixed diet. A 
sudden change from an exclusive diet of breast-milk to a diet of 
cow's milk, broths, and cereals is undesirable, though many infants 
endure it without harm. When artificial food is first given it should 
be in a finely divided form, and attention should be directed to this 
precaution until the molars have been cut. 

The symptoms of too prolonged lactation in the mother arc wcak- 
Miss and disinclination to make ordinary exertions, sweating and 
ana?mia, headache, backache, constipation. The child becomes 
anamiic and restless, and ceases to make weight. 

[Wherever there is unsatisfactory progress with an infant at the 
brejist it should be an invariable rule to have made an analysis of the 
Imast-milk as given in detail below.] 

A healthy infant suckled by a healthy woman increases in weight 
with great regularity, but the rate of increase steadily diminishes 
(see page 18). A slight and short attack of illness produces a slight 
fall in the rate of increase, more serious or prolonged ill-health a 
more marked decrease or actual diminution, which may or may not 
be made good by an increased rate of increase after the nvstablish- 
ment of health. The curve on the next page, taken from one given 
by Sutils, shows the prolonged 'effect produced l)y an attack of gastro- 
enteritis complicated by whooping-cough. In infants fed artificially 
the rate of increase is less regular, and on the average it is smaller 
than in the infant at the breast, though, in those able to take and 
digest considerable quantities of carbohydrate foods, the contrary 
may Ik? the case. Such children, however, are commonly unduly 
fat, and though they may weigh more they have less power of resist- 
ance to gastro-intestinal and febrile diseases than a breast-fed infant. 

If the mother from any cause cease to be al)le to suckle her infant 
her place may be taken by a wet-nurse, but the practice is little fol- 



58 



FOOD. 



lowod in Great Britain. The wet-nurse selected should be between 
twenty-three and thirty years of age, in the second or third month of 
lactation, of robust constitution, and free from any suspicion of tuber- 



FiG. 4. 



Months 



Srami 


Ties 


/ 


2 


3 


4 


5 


6 


7 


8 


3 


10 


U 


12 


,9000 




























fifipn 
























y 


"' 


moo 






















y 


^ 


^ 


I'iPO 




















/'' 


/ 






7000 
















, 


'■'' 




/ 






6500 




















/ 








fioon 












/ 


< 






/ 








'^'iPI 










/ 


/ 




\ 


/ 










5000 










/ 


















45O0 








/ 






Gas 


ro- 


Inte 


nfis 








^000 






/ 








*WJ 


oop 


nqC 


ouqi 








3500 




V'- 
























3000 




'/ 




























Curve showing'the effect of gastro-enteritis complicated by whooping-cough on the weight. The 
dotted line shows the normal curve of increase. (After Sutils.) 

culosis, syphilis, or alcoholism. Her own child should be seen if 
possible, and she should not be accepted if it be in bad health. 

[Composition of Breast-Milk. — Examination of many specimens 
of breast-milk has shown great variations in its composition, both in 
different women and in that of the same woman at different periods 
of lactation. During the first week the breast secretes a fluid some- 
what different from that which is secreted later. At this period, it 
is called colostriuiij from the presence of certain elements known as 
colostrum-corpuscles. These appear under the microscope as large 
cells ; the fat globnles are of larger size than they are later. Analysis 
of colostrum milk shows wide variations in its composition, indicat- 
ing irregularity of mechanism in the mammary gland at this period. 
The breast has not yet got into regular working order ; it is in a 
condition of unstable equilibrium. 

Th(; colostrum is thought to have a laxative effect and to aid in 
expelling the meconium. It normally disappears from the milk at 
the end of a week. Townsend has shown that its persistence is 
accompanied by failure to gain on the part of the nursling. It often 
reappears in the milk later in lactation when the breast is thrown 
into a state of unstable equilibrium from a variety of causes, e. g., 



XUIiSI^^G HABITS. 59 

pregnancy, retnrn of menstruation or nervous excitement, and is in- 
variably aeeoiupanied by digestive disturbance in tlie infant. 

When lactation is well established, analysis of breast-milk shows 
on an average the following composition : 

Reaction . Slii^rhtly alkaline. 

Speoitic Gravity l()*JS-iaS4 

Water 87-88 per cent. 

Total Solids 1.^-12 per cent. 

Fat 3-4 

Snirar ........ 6-7 

Proteids 1-2 

Total Ash 0.1-0.2 

(Kotch.) 

It must be remembered that these figures represent only average 
percentages of the elements of milk, and that we see breast-milk 
varying widely from the above and yet the infant fed thereon thriv- 
ing and doing well ; an important point to which reference will be 
made later in discussing artificial feeding. 

Nursing Habits. — The new-born infimt should be put to the 
breast as so(m after birth as possible, both that the breast may be 
stimulated to more immediate activity, and that the infant may at 
once use the instinct of sucking. Xot much milk is secreted until 
the third day, but the infant will usually be satisfied with a five 
j3er cent, solution of milk-sugar, given in amounts of a half to one 
ounce every three or four hours for the first day or two of life. It 
is imperative that water be given freely in order to dilute the natur- 
ally concentrated urine and to flush out the kidneys. The adminis- 
tration of water at this period should be as much of a routine prac- 
tice as the regular feeding established a little later. It should be 
given from a nursing bottle. 

The young infant sleeps so much during the first few days of life 
that it will often be difficult to arouse him and to make him take the 
breast satisfactorily. Xeverthele.ss the attempt should be made 
at lea.<t every three or four hours, and in some cases oftener. It is 
wis3 first to put him to the breast, then to give him his water ; in 
this way he will be more apt to nurse vigorously for ten or fifteen 
minutes, than if we have fii*st satisfied him with water. Nursing 
once established, regularity should be rigidly enforced. We are all 
but bundU's of hal)its, and it is as ea.'iv to establish good habits as 
bad in a healthy young infant. Irregularity in nursing has an in- 
jurious effect upr>n the cliild, both directly and indirectly ; directly 
by developing at the outset of his career irregular habits in the only 
direction in which he has habits, e. 7., eating and sleeping, and indi- 
rectly by the bad effect upon the breast-milk, too frc(pient nursings 
by repeated stimulation of the brea.st tending to produce a milk more 
concentrated than normal, and too infrequent nursings producing a 



GO FOOD. 



i 



dilute milk. In the one case the nursling's digestive powers will be 
overtaxed, in the other his nutrition will inevitably suffer. He 
should be put to the breast every two hours during the first month 
or six weeks, then every two hours and a half till about the fifth 
month, after which, till the end of lactation, he may go three hours. 
We must remember, however, individual peculiarities in different in- 
fants, and expect to see many nurslings from the first go three hours 
and thrive upon this regime. 

Regularity of habit is the essential point. The day feedings as a 
rule begin at 6 a. m., the last nursing being at 10 p. m. There 
should be but one night feeding, between 10 p. m. and 6 a^ m. dur- 
ing the first two or three months, after which it may be omitted. 

Control of Breast-Milk. — Many cases of breast feeding w^here the 
infant is thriving and gaining steadily in weight and all is going 
smoothly will require but little attention from the physician. But 
those cases, unfortunately numerous, which do not do well, will often 
give much trouble and require much attention to details by the phy- 
sician himself. Too often the advice is given in an off-hand, care- 
less manner to wean the baby and to give him some '^ baby-food,'' 
whereas before taking such an important step, especially in the early 
months of lactation, we should first investigate every case in all its 
phases, determine the trouble and its cause, and seek by all means 
in our power to correct the trouble and continue with the child at 
the breast. So much superior is breast feeding to all other methods 
that we should do our best to continue with it before resorting to 
substitute feeding. 

The symptoms of difficult breast feeding on the part of the infant 
are generally fretfulness andd^issatisfaction with the breast, prolonged 
nursing at each time, gastro-intestinal trouble manifested by vomit- 
ing, diarrhoea, or often by constipation and failure to gain in weight. 
The occurrence of any one of these symptoms should be a signal for 
thorough investigation of both mother and child. The general con- 
dition of the mother must be ascertained, also the details of her life, 
as to diet, exercise, habits of sleep, and general hygiene. Finally, 
but most important of all the breast-milk must be examined. While 
a complete chemical examination of the milk is desirable, it is not 
always possible to have such examination made. Holt, however, has 
devised a method of chnically examining breast-milk, a method of 
great practical value, of which I have made use in many cases with 
satisfaction. The principle of this method is based upon the fact 
that the specific gravity of breast-milk is modified solely by the 
amounts of proteids and fats, inasmuch as the salts are present in 
such small amount and the sugar is remarkably constant. Hence 
the percentage of fat and the specific gravity are obtained, and from 
these two data we make an approximate estimate of the proteids. 



COXTBOL OF BREAST-MILK. 



61 



The method gives accurately the percentage of fat, but only approx- 
imatelv the proteids, showino; whether thev are about normal, much 

ed. 



increased, or much dimiuis 



Fig. 3B. 



Fui 




The various steps areas follows. The milk for examination should 
be either the middle milk, obtained after the baby has nursed two or 
three minutes, or all the milk from one breast, the latter being more 



02 FOOD. 



^ 



desirable. Milk drawn at diiferent times during a nursing varies in 
composition, the '' fore-milk '' being more dilute and the ^' strip- 
pings " more concentrated than the '^ middle '^ or average milk. The 
specific gravity is taken with any small hydrometer. (Fig. 3, A.) 
An ordinary urinometer will do, provided it be small enough. Fat 
lowers the specific gravity, other solids raise it. 

The glass cylinder (Fig. 3, B), graduated in 100 parts and hodl- 
ing ten cubic centimetres, is then filled to the zero mark with the 
milk, allowed to stand eighteen or twenty-fi^ur hours, at the end of 
which time the percentage of cream is noted. The percentage of 
cream is to the percentage of fat as 5 : 3, ^. e., 5 per cent, of cream 
means the milk contains 3 per cent, of fat. If we wish to obtain 
the percentage of fat immediately, e. g., in demonstrating at the 
clinic, Babcock's centrifugal machine may be used. 

Having obtained thus the specific gravity and the percentage of 
fat, we estimate the proteids as follows : 

Calculated. 
IS^ormal fat. Normal specific gravity. Proteids normal. 

High '' " " '* " increased. 

Low '' '' '' '' " diminished. 

From these data we infer that the proteids are about normal, much 
increased, or much diminished. 

This method, of course, gives us information about the fat and 
proteids only , but it is these two elements which vary most in 
human milk, which give the most trouble in infantile digestion, and 
alone of the elements of milk in the present state of our knowledge 
can be modified by the diet and exercise of the nursing woman. The 
most usual variations from the normal are diminished fat, increased 
proteids, and diminished proteids. Earely do we find the fats in- 
creased to such an extent as to cause the nursling trouble in digestion. 
The result of diminished fat is poor nutrition in the infant, with 
sooner or later the almost inevitable development of rachitis. Dimin- 
ished proteids may lead to the same result. An excess of proteids over- 
taxes the infant's proteid digesting power and is apt to produce colic. 

If the fat be found diminished, we may often increase it by giving 
the mother a diet rich in nitrogenous material. The same is true 
with regard to diminished proteids. An excess of proteids is gen- 
erally due to an indoor, sedentary life and a generous table. Obvi- 
ously the treatment for such a condition is exercise in the open air 
and regulation of the diet. 

The urine of nursing women should be examined at least once a 
month, especially if it be found necessary to push the nitrogenous 
part of lior diet to improve the breast-milk. An increase in nitrog- 
enous food may result in renal irritation, if indeed it be not a factor 
in the production of actual organic disease in one predisposed thereto. 



CONTROL OF BREAST-MILK. 63 

either by heredity or previous kidney trouble. The following case 
occurring in the practice of the reviser, shows the necessity of care- 
fullv watchino; the urine in nursino: women : ^[rs. A. B. — 28 yrs. — 
primipara, had suffered for several years with headaches, her physi- 
cian stating that they were not due to renal trouble. Pregnancy, 
delivery and convalescence superintended by the writer and normal 
in all resi>ects, urine being examined re]>eatedly with negative lesults 
from the third month of pregnancy till two months after delivery. 
Baby, three months old, dissatisfied with breast-milk, examination of 
which showed fat 2^^ per cent. More exercise in open air directed, 
amount of meats, eggs and milk increased, resulting in higher per cent. 
of fat in breast-milk. Baby seven months old, mother had severe 
headache similar to attacks several years before, from which she had 
been free during her pregnancy. Urine showed large amount of albu- 
men, fatty renal epithelium, free fat, casts, hyaline, granular and fatty. 
While it cannot of course be certain that the nephritis was caused 
alone by the richly nitrogenous diet of the mother, there can be no 
i doubt that this diet was an important factor in its development. 
< Had a monthly examination of the urine been made, the renal con- 
dition would have been discovered earlier and appropriate treatment 
instituted. The albumen gradually disappeared, but the urine (3 
ars later) contains a low per cent, of urea and the centrifugal sedi- 
ment shows an occasional hyaline cast. No subsequent pregnancy. 
Child healthy and strong. 

While the amount of sugar is usually constant at 6-7 per cent. 

occasionally it will be found below these averages and in such the 

j nursling may fail to gain in weight. The following case illustrates 

I this : A. B. — girl — weight at birth 7J lbs., gained steadily in 

' weight up to fourth week, at which time she weighed 8| lbs. 

Analysis of mother's breast-milk was as follows : 

Water 87.18 

Total solids 12.11 

Fat 4 per cent. 

Proteids 2.78 

Siipar nA"! 

Ash 0.2 

Xo change in regime advi.sed. During the next four weeks she 
j^ained 18 oz., weigliing at 8 weeks, lbs. 14 oz. The breast-milk 
I showed following analysis : 

I Total water 88.14 

' '* solids 11.86 

Fat 4.0 per cent. 

Proteids 2.0 

Sujjar . o. 1 

Ash 0.2 

No change in regime advised. 



64 FOOD. 

During the next three weeks baby gained but one ounce a week, 
only three ounces in all ; thus it will be seen during first eight weeks, 
though gain was steady, it was small, averaging only about 4 ounces 
])er week, and that in the next three weeks there was a decided fall- 
ing off, practically no gain. As the fat and proteids were both high, 
this failure to gain more rapidly was probably due to the low per 
cent, of sugar, 5.1 per cent. And yet this deficit in sugar w^as not 
enough to give rise to apparent trouble. The weekly weighing alone 
showed something Avrong. 

She was given a solution of milk-sugar after each feeding, the 
amount needed being determined in the following manner. 

Average capacity of stomach at 12 weeks . . . 96.6 c.c. 
Amount milk taken ( calculated ) . • . . 96.6 " 

.07 



Amount milk-sugar normally received calculated at 

the maximum 7 per cent. ..... 6.762 g. 

Amount milk-sugar actually received ( 5. 1 per cent. ) . 4.92 " 

Deficit 1-84 g. 

about 30 grains. 

She was, therefore, given 30 grains of milk-sugar in a drachm to 
a drachm and a half of water, after each feeding, a small amount of 
water being given to avoid distension of the stomach. This was the 
only change made in her daily routine of life. She immediately be- 
gan to gain in weight, making 5 oz. in the next three days, and 2 
oz. the next four days, 7 oz. for the week. The milk-sugar was 
continued for about 3 weeks, with average gain in weight of "7 oz. 
per week. It was then dropped, the amount of sugar in the breast- 
milk meanwhile having increased to 6.7 per cent. No explanation 
for this increase. 

The infant was kept on the breast until she was nearly 11 months 
old, when she was weaned onto plain cow's milk, and at one year 
weighed 21 lbs. 

Tiie constipated habit in the mother, so unfortunately common in 
all women, is often the cause of disturbance in the nursling, even 
when analysis shows an average breast-milk. Excessive tea drink- 
ing by the mother is another common cause of trouble in the infant, 
manifested chiefly by peevishness, fretfulness, and a generally nerv- 
ous state. Undoubtedly, under these two conditions, the mechanism 
of the breast is disturbed and it becomes an excreting, as well as a 
secreting organ, the system seeking to eliminate by this route toxic 
materials absorbed from the intestinal tract. Hence digestive dis- 
turbances arise in the infant, in many cases relieved by direct treat- 
ment of the mother, without any measures directed to the infant 
himself Future investigations into the bacteriology of breast-milk 



COW'S MILK. 



65 



will, doubtless, give us information more exact tlian we at present 
possess in this direction.] 

Artificial Feeding. — Stated broadly, the disadvantages of artificial 
feeding of infants are that, except under the most fortunate circum- 
stances, the nutrition is less well maintained, and that there is a 
greatly increased liability to gastro-intcstinal disease. The much 
higrher mortal it v observcxl amonfj hand-fed than amoncr breast-fed 
infants is to be attributed to a combination of these causes, for it is 
obvious that an infant whose nutrition is imperfect, and who is al- 
ready, perhaps, suffering from gastro-intestinal catarrh, will be much 
more liable to suffer from infective diarrhcea and to succumb to its 
effects. 

Cow's milk, which is easily obtained at a moderate price, is the 
basis of must foods given to infants, though the milk of the ass pre- 
sents certain advantages. The following table shows the percentage 
composition of human milk, cow's milk, ass's milk, and of certain 
mixtures, typical of many others, which may be used with most ad- 
vantage to replace human milk. 



Proteids. 



Human mUk 1.82 

Cow's milk 3.52 

Cow's milk with an equal quantity of I 

water '■ 1.76 

Cream mixture (Meigs)' 1.21 

Fat milk (Gaertner) ; 1.76 

Ass's milk- I 1.70 



Fat. 


Sugar. 


Ash. 


3.94 


6.23 


0.31 


3.62 


4.80 


0.70 


1.81 


2.40 


0.35 


3.50 


6.66 


0.25 


3.00 


2.40 


0.35 


1.55 


5.80 


0.50 



Water. 



If Hofmann's estimate of the average amount of proteid in human milk (1.03 per 
nt. ) be accepted, the excess in cow's milk is so great that even when diluted with an 
lal quantity of water there is still too much proteid. 

The main differences in composition between human and cow's 
milk are that the latter contains more proteid and less milk-sugar. 
There are differences also in the salts, cow's milk containing more 
lime and less sodium chloride. The curd formed in the stomach 
from milk is denser the greater the proportion of casein and lime 
salts, and the higherjthe acidity. Cow's milk contains in round 
numlx?rs twice as much casein, and six times as much lime ; it is also 
usually acid. The curd formed from cow's milk is more Indky, less 
flocculent, and more dis]K)sed to form large clots than that formed 
from human milk. J^y diluting cow's milk with an equal (juantity 
of water a fluid is obtained which contains alx)ut the right quantity 

^ [Cream J//r/»/r^ ( Meip* mrnlified hy Kotch). — Cream (about 15 per cent.) 2 
parts; milk 1 part ; lime water, diluted with three-fotirth water, 2 parts ; solution of 
milk-^gar i 3 three-eighth drachms, water 3 fl. oz. ) 3 parts. Or cream ( 20 percent. ) 
3ja6; milk, 5j ; water, "^jv ; milk-sugar solution as above, o'U'^^- Appendix.] 



t)G FOOD. 

of proteid and yields a less dense curd, but it has too little fat, and 
on) V about half the proper quantity of milk-sugar. Many suggestions 
have been made for making good these deficiencies. The addition 
of barley water, which is very commonly practiced, adds a small 
quantitv of carbohydrate, but its main object is to cause the curd to 
be more flocculent. In Meigs' ct-eam mixture, and the various modi- 
fications of it, the defect in the quantity of fat is made good by the 
addition of cream, that in the quantity of milk-sugar by the addition 
of a solution of that substance. Gaertner's ^' fat-milk '^ is made by 
dividing into two equal parts, by means of the separator machine, a 
bulk of milk diluted with an equal quantity of water ; one-half of 
the yield contains nearly all the fat and half the proportion of pro- 
teids, milk-sugar, and salts contained in the original cow's milk. 
This milk contains too little milk-sugar, and to make good this 
Cautley has suggested that the milk should be diluted with a solution 
of milk-sugar instead of w^ith w^ater, before separation. Sexhlet, in 
order to avoid certain difficulties in sterilization, has suggested the 
addition of a quantity of milk-sugar sufficient to compensate not only 
for the deficiency in milk-sugar but also for the deficiency in fat ; 
the composition is based on the fact that 243 parts of milk-sugar are 
required to yield the same amount of work as 100 parts of fat. This 
suggestion, however, ignores the physiological difPerences between a 
carbohydrate and a hydrocarbon, and its ntility is doubtful, at least 
for a permanant diet. 

Condensed Milk is used very extensively for the artificial feeding 
of infants. Its main advantages are that it is cheap and handy, and 
that if prepared fresh for each feeding with boiled water the fluid 
which the child takes is, if ordinary care be exercised, free from de- 
composition and practically almost sterile. The main disadvantages 
attending its use are that it is a cooked food, and that, therefore, a 
too exclusive reliance upon it will tend to produce a scorbutic condi- 
tion, and that, even with the best brands, the quantity of fat in the 
dilution ordinarily used is too \o\n. Very many brands of condensed 
milk sold are made from separated milk and certain very small pro- 
j)ortions of fat (cream) ; many also are loaded with cane-sugar in- 
tended to prevent decomposition, to cover any disagreeable taste, and 
to increase the bulk. Instructions should, therefore, be given that 
the l)rand of condensed milk selected should be guaranteed, by a 
statement on the cover or tin, to contain the whole of the cream of 
the original milk, and to be free from added sugar. The degree of 
dilution to be recommended must be governed by a consideration of 
all the circumstances, and will always be the result of compromise. 
The most careful dilution of the best condensed milk will yield a 
fluid wliicii will contain too much proteid matter and too little fat. 
AVhen condensed milk disagrees, an attempt may be made to over- 



CONDEySED MILK. 67 

come the difficulty by increasing the dihition and adding milk-sugar. 
The use of amdensed milk in temperate^ climates should, however, 
always be looked upon as no more than a convenient temporary expe- 
dient to bridge over an interval of time during which the milk sup- 
ply is under suspicion. In hot climates, and in India especially, 
where the native inditference to cleanliness constitutes a i>eculiar 
difficulty, condensed milk may be nuich preferable to any other ob- 
tainable supply. For such climates, dry, powdered milk ai)pears to 
be particularly suitable.^ 

A great number of imtcnt foods are offered for sale, for most of 
which it is claimed that they are " perfect substitutes" for mother's 
milk. The claim can in no case be substantiated, and in many in- 
stances is in glaring disagreement with the chemical constitution of 
the preparation. Many, for instance, contain large quantities of un- 
converted starch, and should, therefore, be absolutely rejected. In 
others, either the whole of the starch has been converted into dex- 
trose, maltose, etc., or it has been in part converted, and the prepara- 
tion contains sufficient diastase to ensure complete conversion during 
the process of cooking. Such preparations when well made, as many 
of them are, are useful adjuncts to cow's milk. They supply the 
deficient carboiiydrate in a form usually found more palatable than 
milk-sugar, and being easily prepared they are not likely to be al- 
lowed to undergo decomposition owing to being kept after mixing. 

The kind (jf bottle used is a j)oint of considerable importance, and 
one to which sufficient attention is often not given. The modern 
bottle w^ith a long tube well deserves the name often applied to it in 
France, tae-behe — the baby killer — and its use is forbidden by law in 
some countries. The main reason for the favor in which it is held is 
that a full bottle can be prepared and the infant left in its cradle to 
suck at its own will. An infant in good health will not swallow at 
one time more than is good for it, but a slight attack of dyspejisia or 
stomatitis, causing sensations of discomfort in the stomach or mouth, 
will induce it to go on sucking until the bottle is empty, and there- 
after to continue sucking and swallowing air, with the result that it 
begins to suffer from vomiting and flatulent colic. These arc, how- 
ever, minor objections. The great evil of the long-tubed bottle is 
the practical imjM)ssibility of keepiug the tubing clean aud free from 
particles of decomposing curd. Every meal the iufant gets is thus 
inoculate<l with the causes of decomiKjsition, and the liability to 
gastro-intestinal disorder is greatly increased ; the old lK)at-sijaped 
bottle is much to l)e preferred. It is itself of a form which reii<h'rs 
it much more easily cleanefl, it has no long tubi ug, and as it nnist be 
held in the nurse's hand while the infant sucks, the meals are more 
likely to be taken at regular intervals, and to be of a pro|>er (piantity. 
* A dried milk is jirepared by Messn*. Allen and IlanburyH. 



OS FOOD. 

The effect of boiling on milk is to precipitate the lactalbumen, 
which rises as a sciiiii to the surface, taking with it some of the fat 
and casoinogen ; to alter the caseinogen so as to render it less read- 
ily curdled into casein ; to cause the fat globules to run together into 
larger drops ; to alter its flavor ; and to give it a darker (brownish) 
color. None of these changes occurs rapidly, and milk which is 
merely brought to the boil, though it is distinctly altered in taste, loses 
little of its lactalbumen, does not change in color, and the perfection 
of the emulsion of the fat is little diminished. On the other hand, 
the casein clot formed by rennet is more flocculent than that obtained 
from fresh milk, owing to a part of the dissolved calcium salt being 
precipitated as tri-calcium phosphate. 

The milk secreted by the mammary gland in health contains no 
microbes or a very small number. At most the first few drops con- 
tain a considerable number washed, probably from the orifices of the 
ducts. Cow's milk, however, becomes quickly contaminated by im- 
purities on the teats of the animal, the hands of the milker, and the 
vessels into which it is received, by atmospheric dust, and in various 
ways during the manipulations through which it passes before reach- 
ing the consumer, among which must be included the addition of water. 

The diseases of which cow's milk may be the vehicle are (1) Tuher- 
Gidosbi : the milk of a cow suffering from tuberculous disease of the 
udder contains the bacillus tuberculosis in a very virulent state. (2) 
Typhoid fever y the virus of which may find access to the milk in 
various ways, but mainly, probably, through added water. (3) 
Diphtheria. (4) Scarlet fever. (5) Certain forms of diarrhoea, in- 
cluding acute summer diarrhoea. 

Milk which has been carelessly handled by the dealers contains an 
enormous number of microbes. By the time it reaches the consumer 
there may be one or two or three millions in a drachm, and even this 
last number has been exceeded. In much of that supplied in towns, 
especially by the smaller retailers, lactic-acid fermentation has al- 
ready commenced, while among the microbes which it contains are 
some capable of breaking up the proteids of milk with the produc- 
tion of poisonous bodies — alkaloids and peptones. It is to the irri- 
tating qualities thus imparted to milk that diarrhoea produced imme- 
diately by its ingestion must be attributed, while the general toxaemia 
by whicli death is brought about in the more acute cases is due to the 
absorption of tlie poisonous products of proteid decomposition. 

The bactericidal powers of the gastric juice secreted by a healthy 
stomach' afford some protection against the continuance within the gas- 
tro-intestinal canal of fermentations and decompositions which have 

'Soltan Fonwick states (** Disorders of Digestion in Infancy and Childhood,'' 
London, 1897) that in the infant's stomach free hydrocliloric acid can be detected 
only at the end of digestion, and that the development of bacteria may therefore go 
on in its stomach unchecked by the gastric juice. 



coynExsED milk. 69 

commenced in the milk before ingestion, but the toxic bodies? which 
such milk contains are absorbed, while its irritatino: ciualities pro- 
dace catarrh, and such an alteration in the secretions as diminishes 
or destroys their power of checking microbial growth. In conse- 
quence, fermentations and decompositions which have commenced in 
tlie milk before ingestion continue within the gtistro-intestinal 
system. 

In the healthy intant on a milk diet Escherich found that two 
microbes predominated in the loeces, the b. lactis aerogenes and the 
b. coli communis. They produce fermentation of the milk-sugar with 
the production of lactic and acetic acid, and gases (CO^, and H). 
In diarrh(pa a very large number and variety of microbes are pres- 
ent in the fjeces. Booker distinguished no fewer than :>:^, many or 
all of which were capable of causing decomposition with the produc- 
tion of toxic bodies. Thus, severe acute diarrhoea may be produced 
by saprophytic microbes, though it is probable that certain forms of 
acute summer diarrhoea are due to infection of the intestines by spe- 
1 eific microbes. Such microbes have been described by I^esage in 
, acute green diarrhoea, and by Fliigge, who believes that he has iden- 
tified, in a spore-bearing bacillus, the cause of acute summer diarrlwea 
! in one of its forms. This bacillus is spore-bearing, and its spores 
are not destroyed by exposure to a temperature of 100° C. 

By raising milk to the boiling point of water all the bacteria 
i which it contains are destroyed with the exception of the resistant 
1 sjwres of certain of them. Absolute sterilization can be obtained 
; only by prolonged heating at 100° C, or by fractional sterilization. 
I For ordinary purposes, when the milk need not be kept for more 
! than twenty-four hours, this complete sterilization is not necessary, 
I and the term sterilized milk may be applied conveniently to milk 
; which has been freed by heat from the adult forms of bacteria. A 
I large number of apparatus have been devised for this purj)ose. 
( There are two main types : (1) Those in which the milk is sterilized 
, in bulk, and (2) those in which the quantity for each feeding is 
j sterilized in a separate br»ttle. Woodhead gives the following indi- 
, cations for sterilizing milk for domestic purposes. The vessel in 
I which the milk is contained should be placed in a saucepan contain- 
j ing a quantity «)f cold water equal to the bulk of the milk to be 
\ sterilized. The vessel should be provided with a stirrer to be used 
I fn>m time to time so as to maintain an even temperature and the 
I diffusion of the cream. " The water should be l>oiled over a good 
I brisk flame in order that the best results may l)e obtained, and the 
I heating process should be continued until the temperature tin*ough- 
. out the milk has risen to from 8M° to 92° C; in most eases this 
takes place at the end of about twenty-five minutes ; but in order to 
i be perfectly safe it may be recommended that every quart of milk 



70 FOOD. 

treated in this fashion should be heated for half an hour ; that is, 
for about twenty minutes after the Avater in the outer pan has begun 
to boil." These eonditions are fulfilled in a sterilizer designed by 
Catheart of Edinburgh, in which the day's supply can be sterilized 
at once for one child. As will be seen from Fig. 5, it is provided 
with a draw-off tap and with a stirrer, by means of which the cream 
can be diffused through the milk on each occasion before the milk 
is drawn off. Hunter Stew\art,^ working with this apparatus, found 
that after half an hour on the fire the temperature of the milk was 
01° C. (196° F.), and that samples drawn off by the stopcock at 

Fig. 5. 



Cathcart's Sterilizer. A cylindrical block-tin yessel tapering slightly towards the base, and 
provided with a tap at the bottom, through which the milk is drawn off. The lid fits tightly, and 
the line^of junction with the can is rendered air-tight by an elastic band, which is slipped over 
after sterilization is completed. The lid has a wide, funnel-shaped aperture through which the 
milk can be introduced ; the aperture is then closed by a plug of cotton-wool. The sterilizing can 
is placed in a saucepan, of capacity sufficient to receive it conveniently, and containing cold water. 
This is placed on a brisk tire for half an hour. A special feature of the invention is the stirrer, a 
screw-shaped piece of tin provided with a long handle which projects through the aperture in the 
lid ; by its use the milk can be stirred from time to time during the process of sterilization, to 
ensure a uniform temperature throughout the milk. 

two, four, twenty-four, and forty-eight hours after treatment were 
all sterile. The special advantage of this apparatus is that risks of 
contamination of the milk after sterilization are reduced to a mini- 
mum. Aymard's sterilizer, in which also the milk is sterilized in 
bulk, consists of an outer steam-chamber and an inner receptacle for 
the milk provided with a separate lid, and a spout which passes 
through the steam-chamber, to open on the outside. When ready 
for use the covered milk-chamber is enclosed entirely within 
the outer steam-chamber. In the smaller sizes for domestic use 
the steam is generated by heating the water at the bottom of the 
^Brit. Med. Journ., 1896, vol. ii., p. 626. 



CONDENSED MILK. 71 

outer chamber to the boilino' point over a ixas or other stove. The 
milk reaches a temjierature of '200^ F. in about ten minutes after 
the water has begun to boil. Tiie advantages of the a})paratus are 
that it is simple aud easily cleaned, that there is little separation of 
cream or formation of scum, and that owing to the milk vessel 
beintr ontirelv surrounded bv steam, there is little alteratit^n in the 
taste or smell oi' the milk. 

Soxhlet's apparatus may be taken as the type of those in which the 
quantity of milk required for each feeding is sterilized separately. 
The advantages of this metlK^l are that when properly carried out 
the contents of each bottle when given to the child have not suffered 
any contamination after sterilization, and that the milk may be di- 
luted or otherwise modified in various ways before sterilization. 
The apparatus consists of a covered saucepan into the bottom of 
which a sufiicient quantity of cold water is introduced. The bottles 
are placed in a wire-work carrier. Each bottle is closed by an 
india rubber disc, held in place by a metiil cap. The carrier is sup- 
ported in the saucepan a little above the level of the water. The 
saucepan is then heated. Thus, when the water in it begins to boil, 
the bottles are surrounded by steam. The can is kept on the stove 
about three-quarters of an hour. It is then removed and the bottles 
cooled rapidly by running cold water into the can. The loose india 
rubber disc permits the escape of steam from the bottles during 
sterilization, ])ut during the rapid cooling the india rubber comes into 
ccmtact with the rim of the bottle, and by the fall of pressure within 
the bottle, becomes tightly applied. If, then, the bottle be properly 
sealed the upper surface of tlie india rubber disc is concave. When 
required, the bottle is warmed, unopened, l)y placing it in hot water. 
The india rubber disc is now removed, and as this is done a hissing 
noise of air entering the bottle ought to be heard. The teat, which 
should be kept in boric-acid solution (5-per-cent.) when not in use, 
is slipped over the neck of the bottle, which is then ready for use. 
Any milk remaining in the bottle after the meal should not be used 
again. 

The main objections to the use of sterilized milk, over and above 
the |X)ssibility that its continuous use may cause scurvy (7. r.) are : 
(1) That its taste and smell are altered — an objection whicli is 
minimized in the two apparatus for sterilization in Ixilk d(scril)ed 
above, and the force of which is further lessened by the fact that in- 
fants soon become accustomed to it ; (2) that the greater part of the 
carlx)nic acid gas is driven off, which involves an alteration in the 
comix)sition of the phosphates, a iirccijntation of calcium and mag- 
nesium carbonates, and a diminution of the ease of digestion ; (.'5) 
that the emulsion of the fat is less j)crfect than in raw milk, and that 
the fat globules tend to coalesce into drops ; (4) it has been asserted 



FOOD. 



also that the casein is less rapidly digested, though this statement 
has been contradicted. The third objection applies with special 
tbrce to cream mixtures. 

To obviate some of these objections, a process to which the term 
pasteurization is applied has been devised. The main advantages 
claimed for it are that the condition of the fat is not altered, that the 
taste and smell are not changed permanently, that the digestibility 
of the casein is little diminished, and that less carbonic acid is driven 
off. ]Milk kept at a temperature of 65° C. ( 149° F.) for thirty 
minutes is freed from all microbes Avhich can be cultivated by the 
plate. These include the bacillus diphtherise 
Eberth's typhoid bacillus, and the cholera vibrio, 
is with regard to the bacillus of tuberculosis, 
does not long resist a temperature of 70° C. (158° F.). Spores will 
also, of course, escape. On the whole, it may be said that pasteuri- 

FiG. 6. 



(Klebs-Loeffler), 

The only doubt 

which, however. 





Freeiuau's rasteurizer.— i, apparatus arranged for heating the milk before the pail is covered ; 
ii, apparatus arranged for cooling the milk ; A, wire binding the cylinders together, which rest on 
the support C when the milk is beiug heated ; B, one of three short wires which rest on C when 
the receptacle is raised for cooling, as shown in ii. To use : Fill the pail to the groove with water ; 
boil ; remove from stove ; put in milk receptacle (each cylinder must be filled with cold water, 
whether it contains a bottle of milk or not); cover, and leave standing on non-conductor for three- 
rjuarters of an hour. Open, raise receptacle, and cool from faucet. 

zation at 70° C. will render milk so far sterile that it will remain 
free from decomposition for at least twenty-four hours, which is as 
long as it is, under ordinary circumstances, desirable to keep milk. 

The i^rocess may be carried out ^ in a tin vessel, with a tightly- 
fitting lid through which a thermometer passes. The bottle, or series 
of small bottles, containing the milk should stand upon a wire grating. 
Cold water is introduced into the vessel, and the temperature raised 
slowly to ]G0° F. (71° C). The vessel is then taken off the fire 
and kept under a thick cosy for thirty minutes. At the end of this 
time the bottles should be taken out and cooled rapidly. Freeman, 
'Johnstone Campbell, Brit. Med. Journ., 1896, vol. ii., p. 623. 



MILK LABORATORIES. 



73 



of Xew York, has introduocd an ingenious apparatus for domestic 
use. In it a known quantity of water is raised t<^ the boilinir point 
in a suitable eovered pail. The bottles of milk, whieh are stoppered 
with cotton-wool, are placed in a carrier consisting of a series of metal 
cylinders, and introduced into the ]iail, which has been removed from 
the tire. The milk is kept in the covered pail for three-quart(M'S of 
an hour. During the first (piarter of an hour the temperature of tlie 
milk in the bottles rises to 6.")°-(38° C, and a degree or two higher 
in the next ten minutes, and then falls very slowly, so that when the 
can is ojx^ned at the end of forty-five minutes it is still above 65° C. 
The bottles are cooled rapidly by the introduction of cold water into the 
pail, and are kept in a refrigerator until re(piired to be warmed for use. 

The processes of sterilization and pasteurizatiim are, however, de- 
signed to remove microbial contamination, which it would obviously 
be very much better to prevent. Experience shows tliat, with ])roper 
precautions, milk can be collected which, without any preparation, 
will keep sweet and palatable for a much longer period than usually 
intervenes between the hour of milking and the consumption of the 
milk. In the mill: laboratories which have been established in various 
cities of America this has been done, and at the same laboratories the 
milk is so modified under skilled supervision that it contains precisely 
the proportions of fat, proteid, and carbohydrate which the physician 
may presenile. Such modified milk, when obtained under projier 
guarantees as to the health of the milkers and the freedom of the 
herd from tuberculosis, and as to constancy of the composition of 
the samples supplied, apj>ears to be a substitute for human milk as 
nearly |>erfect as can be devised. 

[Milk Laboratories. — The work at the milk laboratories consists 
essentially in the preparation of an artificial human milk, and, as al- 
ready said, the adaptation to the infant's digestive power of requisite 
amounts of fat, proteids, and sugar. The basis of such preparation is 
cow's milk. The prol)lem is the conversion of cow's into human 
milk. For the elaboration of the methods by which this is accom- 
plished, and by which substitute infant feeding is put upon a scien- 
tific basis, the world is indebted to Rotch. 

A comparison of average analysis of cow's and woman's milk 
shows several points of difference, as evidenced by the following 
tables. 



Reaction 

Water . 

Total Solids 

Fat 

Milk-Mi{jar 

Proteids 

A.Hh 



Woman. 

Slightly alkaline. 

87-S8 per cent. 

13-12 

4.(K) 

7.(K) 

1..50 

0.2 



'lightly aciil. 



86-87 per cent. 




4.fK» 


(iincnil 


4..'>U 


averages. 


4.(>0 




0.7 





74 



FOOD. 



Briefly the problem is to convert a preparation slightly acid and 
comparatively concentrated into one slightly alkaline and more dilute. 
More in detail we must modify the cow's milk as follows : the re- 
action must be made slightly alkaline, the total water increased, the 
total solids diminished, the flit be kept the same, the sugar increased, 
])roteids diminished. The various steps by which this modification 
is made are as follows : separation of fresh cow's milk into cream 
and milk, recombining these in various proportions, adding water, 
milk-sugar, and lime-w^ater. The more accurately we can take 
these various steps, the better will be our results, and we have in the 
milk laboratory an institution where this modification is done quickly, 
accurately, and scientifically. 

A case best illustrates the principle upon which we proceed. An 
infiint six months old, deprived of his mother's milk, is to be put 
on modified milk. AVe write a prescription as follows : 



^ 



Per Cent. 



Remarks. 



Fat 4!00 i I Number of Feedings 6 

Milk-sugar 7 00 Amount at each Feeding 5^j 

Albuminoids 150 i Infant's Age 6 mos. 



Mineral Matter - 

Total Solids 12 

Water 88 

lOOiOO 



Infant's Weight 16 lbs. 

Alkalinity 6 percent. 

Heat at 155°F. 



Ordered for Babj X. 



Date, 



.January 1st, 



.189 



j Signature, 



A. B. Smith, M. D. 



This prescription is sent to the laboratory and there from formulae 
carefully worked out, definite amounts of milk, cream, water, milk- 
sugar and lime-water are combined to produce the required percent- 
ages. The resulting mixture is then divided among six tubes or 
bottles, corresponding to the number of feedings ordered ; these are 
stoppered with aseptic cotton, placed in a basket, heated for ten or 
fifteen minutes at the required temperature, 155° to 160° F., and 
then shipped to the baby ready for u.se. Each bottle should be 
heated to the body-temperature immediately before feeding. 



MILK LABORATORIES. 76 

It will readily bo soon that hv varvin^ tlio amounts of the ditlor- 
eiit ingredients used, we oan produeo many eombinations of peroont- 
agos. We thus have great latitude in prescribing and can vary our 
prescription to suit the ueeds of the individual case. 

As has been already stated, the proportions given in the above 
analysis of breast-milk re|>resent a genend average and we sec infants 
fed on a breast-milk ditforinu: widolv from this avoram^ vet healthv 
and thriving. Wo should take the hint and be prepared to vary our 
prescription in different infants. 

The number and amounts of feedings will vary with the age of 
the infant, and, as in breast-feeding, we cannot lay down any 
hard and fast rules which will lit all cases. The intervals between 
the feedings should be the same as already given for breast-feeding. 
The amount at each feeding may be stated broadly as follows : 

Age. Amount. 

1-2 weeks ........ 1-H oz. 

2-4 " 2-3" " 

2-3 months 3-4 " 

4-6 *' 4-6 " 

6-8 " 6-7 " 

8-10 " 7-8 " 

10-12 '' 8-10 " 

Each infant, however, must be a law unto himself, and some will 
require more, others less, than the above amounts at the respective ages. 

Home Modification. — While the modification of cow's milk is done 
nio.st accurately at the laboratory, this institution is at present es- 
tablished only in some of our large cities, and hence the modification 
must oftener be done at home. This can bo accomplished with much 
accuracy, either by the use of the following tables, for which I am 
indei>ted to Kotch, or by the use of an apparatus known as the 
" Materna," devised by Dr. S. V. Haas, and now for sale at the 
large chemical supply companies of our cities. In home modification 
the cream should be a 20^ cream, obtained from any gocxl dairy, and 
the milk-sugar should first l^e dissolved in the water. The total 
amount can, of course, be doubled or tripled, according to circum- 
stances. 

Tables (Rotch). 

Table 1. 

r;ii 1.00 Cream .... 2 ounces. 

Sn^r o.fKj Milk .... 2 (Hinces. 

Proteid-^ 0.7o Lime-water ... 1 ounce. 

Lime-water 5.00 Water .16 ounces. 

20 ounces. 

Milk-sugar .2 meiwures.' 

* Each measure contains 3i drachms. 



FOOD. 



Table 2. 



Fat . 
iSuirar 
Protoids 
Lime-water 



2.00 
5.00 
0.75 
5.00 



Cream 
Milk 

Lime-water 
Water 



Milk-sugar 

Table 3. 



Fat . 

Sugar 

Proteids 

Lime-water 



2.00 
5.50 
1.00 
5.00 



Cream . 
Milk . 
Lime-water 
Water . 



Milk-sugar 

Table 4. 



Fat . 

Sugar 
Proteids . 
Lime-water 



2.50 
6.00 
1.00 
5.00 



Cream 
Milk 

Lime-Avater 
W^ater 



Milk-sugar 

Table 5. 



Fat . 
Sugar 
Proteids . 
Lime-water 



3.50 
6.50 
1.50 
5.00 



Cream 
Milk 

Lime-water 
Water 



Milk-sugar 

Table 6. 

Fat 4.00 Cream . 

Sugar 7.00 Milk 

Proteids 1.50 Lime-water 

Lime-water . . . .5.00 Water 



Milk-sugar 



Table 7. 



Fat . 

Sugar 

Proteids 

Lime-water 



4.00 


Cream . 


7.00 


Milk . 


2.00 


Lime-water 


5.00 


AVater . 



Milk-sugar 



4 ounces. 
None. 
1 ounce. 
15 ounces. 

20 ounces. 
2 measures. 



4 ounces. 
1^^ ounces. 
1 ounce. 
185^ ounces. 

20 ounces. 
2^ measures. 



5 ounces. 
None. 
1 ounce. 
. 14 ounces. 

20 ounces. 
2J measures. 



7 ounces. 

1 ounce. 

1 ounce. 

11 ounces. 

20 ounces. 
2J measures. 



8 ounces. 
None. 
1 ounce. 
. 11 ounces. 

20 ounces. 
2| measures. 



8 ounces. 
2J ounces. 
1 ounce. 
8. J ounces. 

20 ounces. 
2.y measures. 



MILK LMioRA TalllES. 



77 



Taiu.i: 8. 



Fat . 
Sug-ar 

Liine-wator 



4.00 Croam 

7.00 Milk 

•2..")0 Lime-water 

o.OO Water . 



Milk-siiirar 



8 oiinees. 
•") t)unoes. 
1 »»imce. 
• > itunees. 

*J0 oimei's. 
21 im-asui-es. 



Taiuj: II. 



Fat . 
Sii^'-ar 
Proteids . 
Lime-water 



4.00 Cream . 

7.00 Milk 

3.00 Lime-water 

5.00 Water . 



Milk-su.-ar 



8 DUtices. 
7.1 (^unees. 
1 ouiiee. 
'.\\ ounces. 

20 ounces. 
2 niea.-^ures. 



Fat . 
Suj:ar 
Pniteids 
Lime-water 



Table 10. 

(For weaning.) 



4.00 Cream . 

5.00 Milk 

3.00 Lime-water 

5.00 Water . 



Milk-Ruirar 



8 ounces. 
1\ ounces. 
1 ounce. 
3 2 otnices. 

20 ounces. 
1 nn'Msiirc. 



Fat . 
Sugar 
Proteid> . 
Lime-water 



Table 11. 

( For weaning. ) 



4.00 
5.00 
3.25 
5.00 



Cream 
Milk 

Lime-water 
Water 



Milk-sugar 



8 ounces. 
8 (»unces. 
1 ounce. 
3 ounces. 

20 ounces. 
I measure. 



Fat . 
Sugar 
Protei<l- 



Table 12. 

(For weaning. ) 

4.00 Cream 

4.50 Milk 

3.50 



8 ounces. 
12 ounces. 

20 ounce.'*. 



The milk thus prefiared is now distributed among the re«jnisite niunlHr «»f hottlen, 
the bottles plugged w ith abhorlx.'nt cotton and |)a.steurizcd a.s descriU-il ou page 72. 



78 



FOOD. 



Fid. 



VAT 2' 



WILK 



-^-^t-T 


^^) 


2 

2/2% 

6% 
0,8% 

MILK 


6^ 1 
1% 1 

MILK 


CREAM 


CRfAM, 


L.WATER 


IWATB 


WATER 


WAT^f 


M' SUGAR 


1 

d 




Y 



Haas' ^' Materna '' (see cut) is an ingenious 
ai)paratus and simplifies further the method of 
liome modification. While it does not of course 
allow the range of prescribing found in Rotch's 
tables, and so cannot be used for the more 
gradual changes necessary in ill health, when 
the formula; coincide it simplifies home work. 
The apparatus consists of a glass vessel, and is 
made in three sizes, containing respectively 
16, 20, and 24 ounces. The external surface 
is divided by vertical lines into seven sides or 
'^ panels/' on each one of which is indicated 
by horizontal lines the amount of milk-sugar, 
water, lime-water, cream, and milk to be used 
to produce the percentage of fat, proteids and 
sugar marked on the same panel at the top. 
The table shows the arrangement of these 
panels. ^ 



1 

Fat, 2^ 

Proteids, O.65* 

Sugar, Gjt 

Milk 


2 

Fat, lyfk 

Proteids, 0.8'/ 

Sugar, 6$b 

Milk 


3 

Fat, Zi 

Proteids, \io 

Sugar, 6j^ 

Milk 


4 

Fat, zyjo 

Proteids, V/^i 

Sugar, 7/0 

Milk 


5 

Fat, \i 

Proteids, 2^ 

Sugar, 7^ 

Milk 


6 

Fat, zyi 

Proteids, lyfk 

Sugar, Zy^io 

Milk 


Cream 


Cream 


Cream 


Cream 


Cream 


Cream 






Limewater 


Limewater 


Limewater 




Water 


Water 




Limewater 




Water 




Milk sugar 




Milk sugar 


Limewater 




Water 




Water 




Milk sugar 




Barley gruel 




Milk sugar 


Milk sugar 


Gr. sugar 


1 


Y 


X 


X 


X X 






















i\ 



INDICATIOyS FOR MODIFYING. 79 

Six different C(niibinatioiis can thns hv nuulo, and oven more as sn-:;- 
gestcnl l>v Haas, bv eoinbinino- 1(> onnees of one panel witli 1(5 ounees 
of another. The total amount for the day having been prepared is 
then distributed in bottles and pasteurized as already described. 

Indications for Modifying". — The necessity of wide variations in 
moditicd milk has already boen mentioned. Particularly in infants 
acutely sick and in those not thriving- from more or less chronic di- 
gestive disturbance, must we be prepared to vary our modilication 
according to the indications arising in each case. As to exactly 
what those indicatii^ns are, we have yet much to learn. Confronted 
with a case of difficult feeding, the question we ask ourselves is : 
is this child suffering from proteid-indigestion, from fat-indigestion, 
or from sugar-indigestion ? For it is one or more of these three 
substances Avhich is invariably the cause of the trouble. We often 
hear it said that '^ the milk " does not agree with the baby. That is 
as irrational and as indefinite as to say that '' food " does not agree 
with an adult. Which part of the milk, of the food, is at fault ? 
The mistake arises from regarding milk as a simple food, whereas 
in reality it is a very complex food, consisting as it does of fat, 
sugar, jn'oteids, salts and water, essentially the same elements it will 
be noted which make up the diet of the adult, and, as in a case of 
" indierestion " in the adult, we ask whether it is the carbohvdrates 
or the nitrogenous part of the food which is causing the trouble, so 
in the infant we seek to find out whether he be suffering from fat- 
indigestion, sugar-indigestion, or proteid-indigestion. 

An excess of fat is apt to cause vomiting soon after feeding ; oc- 
casionally, also, bits of fat are found in the dejections. It is rare, 
however, to find troul)le arising from a comparatively high percent- 
age of fat. Infants as well as children demand and assimilate large 
amounts of this element. Too little fat is shown by dry constipated 
stools, slow gain in weight, and, if long continued, the development 
of rickets. 

An excess of proteids is indicated by colic and the presence of 
curd in the dejections. 

An excess of sugar is apt to be accompanied with eructations of 

and also with considerable flatulence. Holt believes also that 

' xcess of this element causes colic and green, acid, thin stools. 

We also see soft, flabby flesh in infants taking much sugar; too little 

of the element results in slow gain in weight. 

More clinical data and a more thorough knowledge of physiolog- 
ical chemi-try, however, are needed before we can lay down exact 
ndes for prexribing these three important elements of food. 

The following ca.ses illustrate s^mieof the points mentioned above. 

The first case was an infiint, female, weight at birth lbs., fed on 
barley and milk, Horlick's ct Carnrick'g food, up to two months of 



so 



FOOD. 



i 



iige. The condition then one of marked atrophy, bat without 
marked digestive disturbance. Her subsequent history is shown in 
the following table : 



Date. 



April 21. 
" 24. 
" 27. 
*' 30. 
May 5. 
'' 13. 
" 20. 

" 25. 
June 27. 
July 16. 

'' 31. 
Aug. 28. 
Sept. 9. 

" 16. 

'' 21. 

Oct. 6. 

" 12. 

" 26. 
Nov. 11. 

'' 27. 

Dec. 31. 

Jan. 6. 

" 13. 



Age. 



2 months. 



3 months. 
Rotheln & 

Colic. 

4 months. 



5 months. 

6 months. 



First 
7 months. 



8 months. 



9 months. 

10 months. 



11 months. 



Feeding. 



Fat. 
2.50 % 

2.75 



3.00 
3.25 

3.25 
3.25 
3.50 
4.00 



Tooth. 
4.00 
4.00 
4.00 



Plain 



Sugar. 

6.00 % 

u 

6.00 



7.00 
7.00 

7.00 
7.00 
7.00 
7.00 



7.00 
7.00 
7.00 



6.00 

u 

cow's milk. 



Proteids. 
0.55 % 

0.75 



1.00 
1.00 

0.75 
1.00 
1.00 
1.00 

a 

1.25 

1.50 
2.00 

2.25 

(I 

2.75 
3.00 
3.50 
4.00 



Weight. 



6 lbs. 

7 '' 



12 lbs. 

12 " 8oz. 

14 '' 



14 lbs. 12 oz. 



19 lbs. 



This case did uninterruptedly well. The slow gain during Sep- 
tember and October was undoubtedly due to the low proteids, and 
probably that element could have been pushed more rapidly in this 
particular case, though as a rale we must be cautious in increasing 
this constituent. 

The child is now at four years strong and hearty. 

The next case was more difficult and made less steady progress. 

A male infant, age two months, with a nervous, hysterical mother, 
whose milk showed low fat and high proteids (Holt's method). In- 
fant suffering constantly from intestinal colic and gaining only slowly 
in weight. After a vain attempt to improve the quality of the 
mother's milk, I stopped it at once, and, mindful of the baby's weak 
proteid-digesting power, put him on : fat 2 per cent., sugar 6 per 
cent., proteids | per cent. He stopped crying at once, gained slowly 
in weight, the fat being increased every third day, the proteids 
kept at I per cent, until the tenth day, when he was given and took 
well : fat 3 J, sugar G, proteids |. A week later he was given : fat 
4, sagar G, proteids 1, with disastrous results, vomiting and colic 
starting up in two days. He was then put onto : fat 3J, sugar G, 



lynicATioxs for MoniFYiyo. 81 

albuminoids |, did moII and in a week was airain tried on : fat 4, sniiar 
6, albuminoids 1, which ho took well tor a week, when ai^ain diiros- 
tivo disturbances forced us back to : fat l^, sugar (>, proteids 3,, ujxm 
which he throve for six weeks, when he was promoted to : fat 4, 
sugar 7, proteids 1, doing well on this for two weeks, when, in hot 
weather, a slight diarrhcva necessitated a tenii>orary return to : fiit .*U, 
sugar 0, proteids A. At seven montlis he had l)een for three weeks 
on : tat 4, sugar 7, proteids J, weighed 1() pounds, had two teeth, 
the first of which ap[>eared one week before he was six months old, 
and notwithstanding the erratic course of his diet, his flesh was hard 
and firm and his general condition excellent. His subsequent his- 
tory was uneventful, except that not until his eighteenth month was 
he able to take plain cow's milk. 

Here was an infant, perfectly healthy at Inrth, but his digestive 
powers very early in life impaired by taking his own mother's 
breast-milk, poor in quality, on account of her nervous, hysterical 
temjxrament. As a result of these two factors, poor milk and im- 
p:\ired digestive power, he is weaned at two months, placed on low 
percentages of fat and proteids, the former of which is rapidly in- 
creased, the latter slowly and Avith difficulty, and he arrives at his 
7th month in good general condition, it is true, but with weak pro- 
teid-digestive power, being able to take but |^ of proteids, when 
he should be taking H to 2f.. The case illustrates the trouble 
which these infants with impaired digestive power entail, the neces- 
sity of constant watching and frequent change of formuhe, and also 
the great advantage of feeding exact percentages. 

Diet in the Second Year. — Careful supervision of the child's 
diet during his second year should not be relaxed. Much trouble 
arises during this period from carelessness in the matter of food. 
The majority of children are allowed solid food too early and are 
generally over-fed. As already stated, weaning should be gradual, 
and the child accustomed to the change little by little. 

The chief article of diet during this period must be plain milk. 
In some cases, however, it may be necessary to reduce the proteids, 
an element which we have already seen is apt to cause trouljlc in 
digestion. The same general principles laid down for the modifica- 
tion of cow's milk during the first year of life are also a]ij)lical)le in 
the next year, esjK'cially during the first half of it. A\'e must re- 
member that though we have a child fifteen or eighteen months ohl, 
I he may have the digestive power of an infant six months old. The 
: M-ral condition, not the age alone, must be our guide and govern 

amount and kind f>f fr>od given. 
' At the end of the first year the stareh-iligesting power of the cliild 
lis well developed. The amount of milk-sugar may therefore be re- 
duced, and he may receive his carbfjhyd rates in some other form. 
6 



82 FOOD. 

Cereals may be added to the diet, preferably in the form of oat- or 
barlov-jelly, given with an equal amount of milk. Bread and but- 
ter may also be given with milk. Broth, either chicken or mutton, 
mav be taken for the midday meal. A baked potato may be given 
as early as the thirteenth or fourteenth month, an Qgg at about the 
sixteenth or seventeenth month. Only a few fruits can be taken at 
this period. Orange juice, well-cooked prunes and prune juice, a 
baked apple or apple sauce, a ripe peach or pear may be given with 
benefit, especially if there be any tendency to constipation. 

The above regime is sufficient for the child until about the thir- 
tieth month when we can again increase the variety by the addition 
of meat and vegetables other than potato, such as peas, beans, or 
lettuce. Meat, however, should not be allowed every day until the 
child is about four years old ; it may be given two or three times a 
week. Children Avith " lithsemic ^' tendencies, and those with a di- 
minished excretion of urea from other causes, do better on a limited 
amount of meat. 

The practice of giving tea and coffee to children of all ages cannot 
be too strongly condemned. These stimulants should not be allowed 
until the sixteenth or eighteenth year, several years after the estab- 
lishment of puberty with its nervous disturbance.] 



CHAPTER V. 

ACUTE SPECIFIC INFECTIOUS DISEASES: INTRO- 
DUCTORY. 

Mortality due to the Acute Specific Infectious Diseases — Incubation Period — Pn)j)liy- 
laxis — Complications and Sei]uela' — General Remarks on Treatment : Nursing, 
Food, Drink. Alcoliol — Ilydrotherapeutic Treatment — Antipyretic Drugs — 
Treatment of Adynamia. 

The acute specific diseases are the cause of a very InVli mortality 
among children, and their sequelte are the source of much ill-health. 
It appears desirable to indicate by the followincr statistics, extracted 
from the decennial summary, 1881-fU), of the Rcgistrar-Cieneral, 
their relative importance from this point of view. 

Anxial Mortality per 1,000,CK)0 Persons LiviN<i from the Follo\vin<; 
Acute Specific Diseases at the Age-Periods Stated. 



0-5. 5-10. 



10-15. 



All Ages. 



Whooping-cough 3,370 128 4 45(» 

Measles. 3,131 271 23 440 

Scarlet Fever 1,6«)9 762 153 I 334 

Diphtheria' 6<»0 424 100 ' 163 

Fever ( Enteric, etc. )^ 19<l 221 2;^5 235 

SmaU-pox SO 33 26 45 



The main cause of this great excess in childhood is no doubt the 
absence of acquired immunity, l)Ut children arc more liabh' tlian ad- 
ults to contract certain infectious diseases — for example, mumps and, 
perhaps, scarlet fever and diphtheria. Certain others, as measles 
and whooping-cough, are commonly more severe in them. On the 
other hand, some, of which typhoid fever is an example, are as a 
nde less severe in childhood than at adult ages. 

Infants at the breast enjoy a certain immunity. This is to be ac- 
<"Unted for in .some instances — a.**, for example, typhoid fever — l)y 
the rarity of their exp)sure to the ordinary mode of infection. A 

In the German P>mpire ( MiU. n. d. K.-K. CremmHieUmml) the <leath-rate from 
-.; htheria is much hifht-r. In the age-period 1-15 yean<, the rate wa-s 3,2(K> |>er 
million livinp in \^'X1, and 4,4<M> in 1H93 ; but deaths attributed to croup were (no 
donl»t, cr»rrectly > clasfsed with dii>htheria. 

^ " Typhus,' Enteric Fever and Ill-defined Forms of Continued Fever." 

83 



84 



ACUTE SPECIFIC INFECTIOUS DISEASES. 



similar explanation, however, is not applicable to some other dis- 
eases, of which measles may be quoted as an instance. 

The diseases of this class possess certain peculiarities in common 
beyond the fact that all are communicable directly or indirectly, or 
in both ways. In their course three stages may be distinguished — 
the period of incubation, of fever, and of convalescence. 

The incubation period — the interval between exposure to infection 
and the development of the characteristic symptoms — may be short, 
as in diphtheria, scarlet fever, influenza, cholera ; or long, as in 
small-pox, measles, Avhooping-cough, mumps. The period of incu- 
bation is not constant in any disease, and the main variations are 
set out in the accompanying table. The period during which the 
disease is infectious, and more especially the period at Avhich it is 
most infectious, is not the same in all. Thus measles, mumps, 
rubella, and whooping-cough are very infectious at an early stage, 
before the symptoms are characteristic ; whereas scarlet fever and 
small-pox, though infectious at an early stage, become more danger- 
ous during the later stages. On the whole, it may be said that the 
shorter the period of incubation the longer the subsequent period of 
infectiousness : 





Incubation Period 
(days). 


Duration of Infection. 


Period of 
Observa- 
tion 
(days). 




Usual. 


Extremes. 


Beginning. 


End. 


Small-pox 


12 
14 

9 or 10 

14-18 

1-3 

3 
7-10 

2 
12-14 

21 


8-20 
11-19 
4-14 
8-21 
1-7 
1-5 
5-13 
1-7 
8-23 
14-25 


Prodromata 

Onset 

Prodromata 

u 

Onset 

Prodromata 
Incubation 
Onset 
Prodromata 


End of convalescence 

Ditto 

3 weeks 

1 or 2 weeks 

Uncertain 

10 days 

Uncertain 

Undetermined 

End of convalescence 

3 weeks 


21 


Varicella 


20 


Measles 

Rubella 

Scarlet Fever 

Influenza 


15 
22 

7 
6 


Whooping-cough.. 
Diphtheria 


14 

3 


Enteric Fever 

Mumps 


24 
26 







In the prophylaxis of acute specific diseases we have to consider 
the prevention of the spread of the disease to uninfected persons, and 
the prevention of complications in patients already suffering from it. 

For the prevention of the spread of the disease regard must be had 
to the isolation of the patient throughout the period during which 
he is infectious, to the disinfection of excreta (stools, mucous and 
other discharges), and to the observation of susceptible persons who 
have been exposed to the infection. Early diagnosis is important, 
more especially in those diseases, such as measles, whooping-cough, 
and mumps, in which the patient is very infectious during the early 
stage. Before the appearance of the characteristic symptoms a posi- 
tive diagnosis may often be impossible, unless there be an epidemic 



ISTRODUCTORY. 85 

in the district, or the chihl he known to have heen exposetl to infec- 
tion. In all donhtfnl cases a irnarded opinion slunihl he oiven, and 
the child isolated and kept nnder ohservation. It is ditlicnlt in an 
ordinary private house to obtain eiFective isolation of scarlet fever or 
small-pox, and these diseases are of so serious a character that if a 
suitable fever hospital is available it is l)etter for all parties that j)a- 
tients suffering from them should be removed to it. Diphtheria and 
enteric fever can be isolated eiiectively in a private house if a suit- 
able room and intelligent nurses can be obtained ; but in small houses 
and tenements a patient ouirht to be removed, if possible. Measles, 
who<^pinir-cough, and mumps can be isolated in a ]n*ivate house in a 
suitable room : but many tlisappointments will be met with, owing 
not to the failure of isolation but to the fact that the infection has 
commonly been spread to other susceptible children during the pro- 
dromal stage. The period of time for which a person who is con- 
valescent should be isolated varies in different diseases, and some 
general indications will be found in the table. In measles, rubella, 
whooping-cough, and mumps, etilux of time in itself diminishes the 
risk of infection ; but in scarlet fever, small-pox, and diphtheria, this 
is not the case, since the infection may ]x*rsist for long periods in 
the discharges of the skin and mucous surfaces, or survive in Ibmites, 
Every case must be decided after a full consideration of all the cir- 
cumstances of the patient and his surroundings. The responsibility 
of disinfection after specific diseases — after those at least which in 
Great Britain must be notified — should be thrown u])on the sanitary 
authority. During the fever the stools and urine, discharges, linen, 
and feeding and other utensils must be disinfected. For stools, 
urine, and discharges perchloride of mercury solution, 1 in 1,000, is 
to be preferred ; for linen, a covered vessel containing 1 in 20 car- 
bolic acid, in which the articles should be completely immersed. 
Utensils should be emptied and cleaned with soda solution, rinsed 
with |x^rchloride solution and with tap water, and left to drain, or 
placed in a solution of l)oracic acid. Small articles are convi'uiently 
sterilized by boiling. The persons in charge of the patient should 
wear cotton gowns and aprons, attend scrupulously to personal 
cleanliness, and after handling the ])atient, his linc^n or discharges, 
ehould wash the hands, and then rinse them in a 1 in 2,0(10 per- 
chloride. 

Precautions of this nature serve also greatly to diminish the risk 
of many complications, especially broncho-pneumonia, which is the 
main cause of the large mortality produced by measles and whoop- 
ing-cough. When it is necessary to nurse several cliildrcn together, 
separate feeding uten-ils sliould be u-cd for each. H'one of tlic mun- 
ber develop broncho-pneumonia, it should be isolated froni tlir ..ihcrs 
ID a separate room. 



so ACUTE SPECIFIC INFECTIOUS DISEASES. 

If a child has been exposed to an infectious disease from which it 
is known not to have suffered, it is often of very great importance to 
decide the length of time during which it must be kept under obser- 
vation before it can be declared to have escaped the infection. The 
])eriod should exceed the longest known period of incubation of the 
disease in question, and care must be taken to ascertain at its termi- 
nation that the patient is free from all prodromal symptoms. 

Complications and Sequelae. — The number and variety of the 
complications and the sequelse which may arise in connection with 
the acute specific febrile diseases is immense. There is no organ or 
system of the body which may not become affected, and the nature of 
the complication is determined in part by the special manifestations 
of the infection, and in part by the constitution of the individual ; 
that is to say, the breakdown is most likely to occur, other things 
being equal, at the point of least resistance. Among the most fre- 
(juent and dangerous complications are affections of the respiratory 
system, and local inflammations such as otitis or ophthalmia, due to sec- 
ondary infection. They are therefore accidental, and to a greater or 
less degree in individual cases, preventable complications, and the 
reader is referred to the pages in which the diseases of the several 
organs are considered. Gastro-enteritis and colitis also, by which the 
acute specific diseases are very apt to be complicated in childhood, 
are best studie<i in connection with these disorders when due to other 
causes. 

Any acute febrile disorder may be complicated by albuminuria, 
and the acute specific diseases afford no exception to the rule. The 
condition will be discussed subsequently, when the diseases of the 
kidney come to be dealt with. But it must be observed here that 
the presence of albumen in the urine during the febrile stage is of 
very different significance in prognosis from its appearance or per- 
sistence after the febrile movement due to the specific infection has 
passed away — in the one case it may be attributed to the transient 
effects of toxaemia on the kidneys ; in the other to local disease of 
these organs. 

Mental Disorders. — The delirium which attends the febrile stage 
does not call for special discussion here, but after defervescence 
various disordered mental states may cause much anxiety. The 
most common is a condition of mental apathy, which may amount to 
actual dementia. Its cause is to be found in the condition of defec- 
tive general nutrition and anaemia produced by the disease, and in 
the effects of severe or long-continued toxaemia on the nutrition of 
the brain in particular. In other cases attacks of delirium and 
maniacal excitement recur frequently during convalescence. Such 
attacks are specially prone to come on after meals or at night ; that 
is to say, at times when there is a physiological tendency to cerebral 



COMPLICATIONS ASD SEQUELAE. 87 

auivinia, and they are to he attrihuted to an exaggeration of this ten- 
deney, which produces the greater effect owing to tlie existence of 
general anivmia. The occurrence of nocturnal delirium may give 
rise to apprehensions of relapse of the disease, but the temperature is 
usually normal or subnormal. Apathy or dementia is most often a 
sequela of typhoid fever or measles, but it may occur after other acute 
febrile diseases. After influenza, an allied condition described under 
the term somnolence is observed occasionally in children and even in 
infants, as in adults. Sometimes, especially after typhoid fever, de- 
lirium and apathy alternate, the patient being apathetic by day and 
delirious by night. Mania and maniacal excitement are observed 
more often as a sequela of scarlet fever than of the other febrile dis- 
eases,* but are not unknown after others, especially typhoid fever. 
Occasionally a conspicuous feature of the apathetic state is mutism 
and in some instances a condition of aphasia }>ersists for some weeks 
after the patient has made great improvement in other respects. 
This is observed most often after typhoid fever. The child may be 
able to see and hear, even to write, but is unable to utter a word. 
The power of speech returns as a rule at first slowly and then very 
rapidly, so that complete aphasia may in a few days be succeeded by 
free speech. 

In the treatment of apathy, nocturnal delirium, or dementia after 
acute febrile diseases, the main indication is to improve nutrition by 
suitable diet and tonics, and to diminish the auicmia by the adminis- 
tration of iron salts, of which the perchloride is the best if it can be 
borne by the stomach. Nocturnal delirium can usually be controlled 
by moderate doses of potassium bromide given during the afternoon 
and evening, but a dose of chloral may be necessary in some cases 
to procure sleep. 

Nervous disorders are among the most serious, though least fre- 
quent, complications. The occurrence of hemiplegia is discussed 
elsewhere, but generalized nervous disorders also occur. After 
small-pox, measles, scarlet fever, typhoid fever, whoojung-cough, in- 
fluenzii, and also in association with erysipelas, acute pneumonia, and 
perhaps ague, cases are occasionally met with which present symptoms 
of widely diffused nervous affections probably allied pathologically to 
diphtherial j^iralysis. They may be classified as fi)llows : (1) Cases 
of "extensive, ascending, diffuse, or disseminated" ])aralysis, resem- 
bling diphtherial paralysis. (2) Cases in which, with some symptoms 
similar to those of the preceding group, the most prominent symptom 
is incoordination. (3) Acute disseminated myelitis. (4) Cases pre- 
senting at a later date symptoms resembling disseminated sclerosis 
(false disseminated sclerosis). 

In cases l)elonging to the first and scccjnd chiss the paralytic or 
'Cfery". Mercier, Brit. Med. Joum., 1883, vol. ii., p. 630. 



88 ACUTE SPECIFIC INFECTIOUS DISEASES. 

ataxic symptoms are observed usually first when convalescence has 
already commenced, but in those in which disseminated myelitis de- 
veloped, or in which symptoms resembling disseminated sclerosis 
have subsequently appeared, convulsions have occurred during the 
febrile stage, or stupor or somnolence has been noticed during that 
stage. The patient on recovering consciousness is unable to speak, 
and is found to be suffering from extensive paralysis or paresis, or 
from ataxia. From this condition he may recover completely, or he 
may develop symptoms resembling those of disseminated sclerosis, 
but with this difference, that the disease is not progressive but rather 
regressive. In the cases fatal at an early stage, the changes in the 
central nervous system appear to have been mainly or primarily 
vascular ; and it seems reasonable to assume that in those cases in 
which complete recovery takes place at an early date the symptoms 
are due to vascular derangement. The recovery from diphtherial 
palsy is not always complete, and in a few cases it has been known 
to be followed by this condition of ^' false disseminated sclerosis." 

The observation lends support to the view that cases of the kind 
here under consideration, whether instances of transient paralysis, of 
ataxy, or examples of a train of symptoms resembling disseminated 
sclerosis of the cord or hemispheres, are due to the action on the 
nervous centres of soluble toxins circulating in the blood. ^ 

Muscidar atrophy resembling that produced by acute polio-myelitis, 
and due probably to a lesion in the same region, has been observed 
occasionally as a sequela of acute specific diseases. Complete re- 
covery has in some cases occurred, but in others the palsy has been 
permanent. 

General Remarks on Treatment. — In treating a case of proved 
or suspected infectious fever, the first step is to isolate the patient in 
a well ventilated room, from which carpets, heavy curtains, and 
superfluous articles have been removed. This is recommended in 
the interests not only of others, since such articles are difficult to 
disinfect, but also of the patient, since they are a cause of dust, which 
may be the source of secondary infection. 

Nursing. — A trustworthy trained nurse should, if possible, be ob- 
tained. She should be competent not only to attend to the comfort 
and cleanHness of the patient, and to the regular administration of 
fi>od and drugs, but also to note the general progress of the case, and 
the time of the supervention of new symptoms, for the information 
of the medical attendant. She should be made responsible for the 
ventilation of the room, the temperature of which should be kept 

' This subject will be found more fully discussed in the papers by Marie [Prog. 
Med., 1884, Xo. 15, et .^erj. ) ; by Whipham and Myers (Clin. Soc. Trans., xix., p. 
164) ; by Barlow [Jlled. Chi. Trans., Ixx., p, 77) ; and by the present writer (Ibid., 
Ixxvii., p. 57). 



GENERAL REMARKS OX TREATMENT. 89 

about 06° F. or, in influenza or measles, 58° F. She should also 
attend to the proper treatment, with a view to their disinfeetion, of 
exereta and all diseharges, or objeets soiled with them, sueh as linen, 
and feeding and other utensils. 

Food. — The main objeet in the symptomatie treatment of fevers is 
to maintain the energy and nutrition of the nervous and museular 
tissues. The diflieulty is the greater the more intense the infection, 
the less the power of resistance of the individual, and the higher the 
fever. The probable duration of the specific process will influence 
treatment, since the task is more diflicnlt in fevers of long duration, 
such as typhoid fever and variola. The diet should contain appro- 
priate quantities of proteid, carbohydrate, and fat. There is often 
a disposition to give too small a quantity of carbohydrate food ; it 
must be remembered that carbohydrates added to the diet increase 
the amount of proteids assimilated, and diminish the loss. Gelatine 
also is an economizer of proteid waste. In arranging a diet, es- 
I pecially in an illness which is likely to be prolonged, it is important 
] to avoid monotony. In children the staple article of diet should be 
i milk, which may be modifled in various ways, as by dilution with 
barley water or by peptonization. The value of jieptonized milk, 
diluted if necessary, is very great in severe cases. The amount of 
' carbohydrate in the diet may best be increased by giving wheat, oat, or 
' barley gruel, which is more palatable if made with milk and sweet- 
> ened, and there is no objection to the use of lemon or other sim})le 
flavorings. Soups, if carefully made and well flavored with vege- 
I tables passed through a sieve, afford a useful variety often much 
j appreciated by the patient, and one which has a favorable influence 
I on the bowels. Beef-tea should be banished ; even when well made 
I it contains little nutriment, and the ordinary product is poisonous. 
I Drink. — The person in charge of the child should be impressed 
I \vith the fact tliat milk is a food and not a beverage. Children with 
! fever often suffer intensely from thirst, and if this fact be not real- 
I ized are very apt to be given far too much milk. Barley water, 
[ which may l)e flavored with lemon, fresh lemonade, seltzer water, 
I and other simple beverages sliould he allowed. (Fresh Jj'inondde. — 
I Rub two or three lumps of white sugar on the clean rind of a lemon, 
I squeeze out the juice and remf»ve pips and shreds ; place together in 
\ a jug with a bottle of soda-water ov an equal quantity of boiled (cold ) 
I water. Appendix.) The drink may be given at the ordinary 
I temperature of the room. If the thirst be associated with stomatitis 
or pharyngitis, small sips of iced water may be given, or in children 
old enough t<^» be trustefl morsels of ice may l)e sucked. 

The danger of over-feeding must be avoided by prescribing the 
quantity of food, and directing an appropriate amount to be given 
at regular intervals. As a general rule, the indication is to give 



90 ACUTE SPECIFIC INFECTIOUS DISEASES. 

small quantities at short intervals. It is difficult to lay down any 
rules as to (quantity, as a judgment must be formed in each case 
from the indications afforded by the tongue and the condition of 
the digestive organs ; but if a child between one and two years old 
be taking daily a pint of milk, in various forms, it may be considered 
to be having quite as much as is desirable. 

Alcohol. — The routine resort to alcohol is to be condemned, but it 
is a valuable drug when a stimulant is required. For this purpose 
good brandy is probably the best. The quantity to be given should 
be ])recisely stated. 

Antipyretic Treatment. — Since the febrile state is the natural reac- 
tion of the organism to infection, it may be assumed to possess a use- 
ful function ; and it might therefore be argued that attempts to reduce 
the temperature are irrational. The theory, so far as it tends to ob- 
viate unnecessary interference, may have a wholesome influence ; but 
the reaction may be excessive, and, apart from the question of hyper- 
pyrexia, may call for treatment. A rise of temperature is attended 
by alterations in the metabolism of the tissues, an increase of oxida- 
tion, and an arrest of digestive secretions. A moderately high tem- 
perature, Avhich does not produce a marked effect on the heart or 
nervous system, and is not long lasting, does not call for antipyretic 
treatment. On the other hand, if, owing to the height to which the 
temperature reaches or the length of time for which it remains ele- 
vated, there is a marked diminution in the energy of the nervous 
system or heart, then it will be necessary to take means to reduce it. 

Hydrotherapy. — The application of cold to the surface by baths or 
wet packs is, as a general rule, the most efficient and safe method for 
reducing temperature. The antipyretic effect is produced partly by 
the direct abstraction of heat, partly through the peripheral nerves, 
which, Avhen stimulated by the cold, produce an effect on the nervous 
centres, diminishing coma and delirium, improving the action of the 
heart and the respiration, and stimulating the heat-regulating mechan- 
ism. The effect of the application of water to the surface at a tem- 
perature lower than that of the body in fever is very considerable, 
and is especially marked in children. Thus Eross ^ found that in 
infants with temperature at about 104° F., a bath for ten minutes 
at 95° F. caused a fall of 3.7° to 9° F., the greater part of which 
took place usually during the bath, but part during the hour or two 
after ; then the temperature began to rise again, but did not reach 
its former height for three, four, or even ten hours.^ The main ob- 
jection to the bath is that its action, even when the water is luke- 

'Jahrb.f. Kinderhlkde., Bd. xxxii., s. 83. 

2 Eniss {loc. dt. ) found also that even in healthy infants a bath at 80° to 86° F. for 
10 minutes produced a fall of 3° to 5.7° F., the normal temperature not being regained 
until three to five hours later. 



A 



GEXERAL JiEMARKS OX TREATMENT. 91 

Avarra, is apt to be too energetic. Although it is true, as a geiu'ral 
proposition, that the U^wor the teniper.iture of the hath and the hmger 
it is applied the greater the etf'eet on the temperature of the body, 
yet it is not easy to foresee in ehihh-en tlie degree of tlie effect, owing 
to the rapidity witli which in them tlie temperature may be reduced. 
The hikewarm bath is, however, a very vahiable therapeutic means 
if it be remembered that the effects which it prochices nnist be 
watched carefully. The cold bath, which has a very energetic action, 
may be of use in those rare cases in which, during the early stage of 
a fever, the condition has become dangerous, owing to the intensity 
of the cerebral symptoms. Such a bath not only reduces the tem- 
perature but stimulates the nervous system and the heart. A similar 
effect is more safely obtained by placing the child in a warm bath 
and pouring cool or cold water on to the head and shoulders. If a 
suitable bath is not available, or should its use for any reason appear 
inadvisable, the temperature may be reduced 2° to 3° F. by strip- 
ping the patient and applyiug to the surface a sheet wrung out of 
water at do^ to 60° F. This sheet is removed every five minutes 
for four or five times, the last sheet being used as a pack, in which 
the patient is kept covered with blankets for twenty minutes or half 
an hcnir. 

Baths : Warm Bath and Pack. — The bath should be large in pro- 
portion to the size of the child, and a large quantity of water (at 
first at the temi)erature of 9o° F.) should be used. During the bath, 
which should last twenty minutes, the temperature of the water should 
be raised to 104° F. or 10o° F. by the careful addition of hot water. 
The child should be kept immersed up to the neck, and a blanket 
should l>e thrown loosely over the bath, and held around the neck. 
Meanwhile, a bed is to be prepared thus : — Turn down tlie bed- 
clotiies, and put a blanket on the bed, so that it projects a little over 
the foot. Immediately before the child is to be taken out of the 
bath, a fairly thick sheet, thoroughly wrung out of hot water, is 
placed over the blanket. The patient is now lifted out of the bath, 
and laid on the sheet, in which it is tightly wra})pe(l up, with the 
arms inside ; the part of the sheet which projects beyond the feet is 
folded and tucked firmly under the feet. In adjusting the sheet, care 
must Ik? taken to avoid cre<ases, and to tuck it in firmly around the 
neck. The blanket is now folded around the |)ati('nt, great care being 
taken to avoid any looseness or irregularity l)y which air could enter. 
The bed-clothes are now pulled down, and tucked in firmly at the 
foot, sides, and neck, so as to exclude the air. Profuse perspiration 
commonly begins in a short time. The patient should niiiain in 
the pack aU>ut an hour. The pack is then undone, and the patient 
quickly rubbed down with a warm, rough towel, put into a second 
bed (which has l^een well warmed), if such be available, and covered 



92 ACUTE SPECIFIC INFECTIOUS DISEASES. 

with plenty of light, warm bed-clothing. The shift from the pack 
to the bed must be done as rapidly as possible. In mild weather the 
window may be open while the patient is in the pack, but draughts 
should be avoided. (Jiirgensen.) [Appendix.] 

Antipyretic drugs are now much less used than was the case 
formorlv. The reduction of temperature effected by quinine lasts 
loni2:er than that produced by other antipyretic drugs, but it is apt 
to derange the stomach. If the sulphate is used, it should be given 
every six or eight hours in doses of about 1 grain for each year of 
life. Quinine tannate in powder is more readily taken, since its taste 
is less bitter, but the dose must be double that of the sulphate. 
Quinine may also be given by subcutaneous injection, and the best 
salts for the purpose are the hydrochlorate or hydrobromate. Anti- 
pyrin and antifebrin produce a depression of temperature which is of 
shorter duration, but the former in particular has a sedative effect, 
which is often beneficial. 

Adynamia, characterized by great nervous depression and cardiac 
failure, is the cause of death in many severe cases. Warm baths of 
short duration, with, if the temperature is high, cool affusions to the 
head, should be employed and their effects watched, or an ice-cap 
may be applied to the head. The failing heart is stimulated by these 
means. For this purpose alcohol is useless, if not injurious, except 
perhaps in severe diphtheria and fevers partaking of the septic type. 
Digitalis is of somewhat uncertain advantage ; it is best given in one 
or two full doses, and may be followed or replaced by strophanthus. 
Failing heart, accompanied by coldness and blueness of the extrem- 
ities, dyspnoea and pulmonary oedema, should be combated by small 
doses of sodium nitrite {-^-^ to i gr.) or nitro-glycerine (-g-^-jj- to y^^- 
gr.).^ Strychnine is probably the most valuable drug in the treat- 
ment of the general symptoms of adynamia ; an infant of a year old 
may have a hypodermic injection of ^^-^ grain three or four times a 
day, and the dose may be increased considerably if necessary. Hypo- 
dermic injections of camphor are much used in Germany, and of 
caffeine in France, but the latter is unsuitable if there are symptoms 
of cerebral irritation. Of camphor 5 to 15 minims of a 10-per-cent. 
solution in oil may be given to children of five or six years, even as 
frequently as every hour, the indication being failure of the pulse. 

It may also be given as follows [Appendix] : 

Elixir ('amphone (Martindale ct Westcott) 

Spirit of Camphor ^x 

Syrup , 3v ' 

Distilled Water 5J 

Contains cam|)hor gr. iv in ^j. 

' Possibly erythrol tetranitrate might be more efficacious, since its action is more 
prolonged. 



GENERAL REMARKS OX TREATMENT. 93 

Caffeine may be administered by prescribing strong blaek cofree, 
wliich, however, is not suitable for young children. For subcutane- 
ous injection, catfeine should be prescribed in a watery solution of 
sodium benzoate. The dose for a child of two vears should be 2 



It is prepared as follows [Appendix] : 

In water jj cH^^olve sodium salicylate gr. xvj or sodium lionzoate ,e:r. xx, and 
add caffeine gr. xx. Sterilize by boiling for 1") minutes. iJr. j in w^ iij. 



CHAPTER VI. 
ACUTE SPECIFIC INFECTIOUS DISEASES {continued). 

Small-pox — Vaccination — Symptoms and Treatment of Small-pox — Varicella — Mea- 
sles — Rubella — Scarlet Fever. 

Small-pox, Avhich used to be an almost inevitable accident of 
human life, has now, in vaccinated communities, become a rare dis- 
ease, especially in childhood. For example, of 1,117 cases admitted 
into the hospitals of the Metropolitan Asylums Board in 1894, 127 
were children under seven years of age, and 178 children from seven 
to fourteen years. Of the 127 children under seven. 111 had not 
been vaccinated, and all the deaths (thirty-five) at this age-period 
occurred among them. Children unprotected by vaccination are 
very liable to small-pox, and their mortality is high. Of the unvac- 
cinated persons who died in England and Wales, in 1881-92, 38.9 
per cent, were under five years old, and 72.9 per cent, under twenty 
years. Of the vaccinated persons who died of small-pox (including 
in this number those as to whom no statement as to vaccination was 
made) 16.8 per cent, were under five years, and 38.9 per cent, under 
twenty years. The relative rarity of small-pox in childhood in Great 
Britain is undoubtedly due to the fact that the majority of children 
are protected by vaccination in infancy, while re-vaccination, neces- 
sary to renew protection, which diminishes after eight to ten years of 
age, is not so universally practiced. 

Vaccination. — When vaccinia runs a normal course a small papule 
is observable at the points of insertion about thirty-six hours after 
vaccination ; this grows larger, and about the fifth day shows a ve- 
sicular top with a depressed centre. The vesicle enlarges, and be- 
comes surrounded by a red, thickened edge. It attains its charac- 
teristic stage on the eighth day, when it is a large flat, umbilicated 
vesicle of an opaque white or opalescent color. For the next two 
days it enlarges slightly, and becomes surrounded by a wide areola 
of inflamed skin. On the eleventh or twelfth day the stage of re- 
gression begins ; the areola becomes less marked, the vesicle flatter, 
its contents more opaque. By the fourteenth or fifteenth day it is 
converted into a scab, which is detached after a week or two weeks 
more, leaving the characteristic depressed cribriform scar. At the 

94 



I 



SMALI^POX. 95 

height of the vaccinia there is usually some enlargement of the axillary 
glands, which are tender/ Suppuration occurring under tlic scar is 
due to secondary infection by pyogenic organisms, and should be 
treated locally by antiseptic applications. 

The degree of immunity conferred by vaccination varies, but when 
efficiently j>erformed it is almost complete, and the individual, if ex- 
posed to the infection of small-pox, either escapes or, if he C(.ntract 
the disease, suffei*s from it in a more or less mild form — modified 
small-pox. The duration of the protection afforded by primary vac- 
cination in infancy is uncertain, and re-vaccination is necessarv at 
the age of nine to ten years. During an epidemic re-vaccination 
should be practiced at the age of seven years. 

In presence of an epidemic there should be no hesitation in vacci- 
nating the youngest infant. Under other circumstances, vaccination 
should be performed between the ages of three and six months. It 
should not, under ordinary circumstances, be performed if the infant 
is suffering from any pyogenic form of dermatitis, nor in syphilitic 
children unless otherwise in good condition, nor if there be any 
known source of erysipelatous contagion. A certain amount of 
judgment must be exercised in the case of marasmic children ; as a 
rule they bear it well, and it should not be deferred if the disease be 
epidemic. As the vaccination vesicle is attended by a good deal of 
itching during the stage of areolation, the child is apt to scratch or 
rub, and so break the vesicle, which then usually becomes the seat 
of suppuration. Under such circumstances care should be taken to 
prevent secondary inoculations on other parts of the body by the 
finger-nails or clothes. The application of boracic ointment is often 
useful if the p(»ck be ru])tured. Various rashes may occur during 
the time of the maturation of the vaccine vesicle. In my own ex- 
perience the most common has been a discrete papular rash, some of 
the papules showing slight vesiculation. Irregular erythematous 
rashes, which sometimes leave a slight yellow pigmentation, may also 
be observed ; but the most frecpient rash would ap])ear to be roseola, 
coming out from the eight to the eleventh day after vaccination. 
All these rashes are rare, and the rarest general affection is true 
generalized vaccinia. When vaccinia runs its cust<»mary localized 
course it causes very little disturbance of the general health, and ele- 
vation of tem|)C'rature is not a constant sym])tom. Ke-vaccination is 
often attended by more widespread hx'al reaction and more general 
disturbance. The use of impure vaccine (from contaminated vesicles, 

' When small-pox was inoculated a papule appeared f>n the sei-ond day at the point 
of inoculation : this ha^l V>eeonie a vesicle on the fourth and a pustule on the eighth, 
on whieh day the patient had rigors, much l<K-al swelling; with adenitis, and fever. 
The f»rdinarv small-pox eruption ap|»eared on the eleventh day. The coun*e f>f the 
local le>ion after vaccination and variolation respectively may he studierl in the iK-au- 
tifal series of drawings reprcKluee<l in the lirititth Mctliral Jnnmnl of May 2.'., 1H«*6. 



96 ACUTE SPECIFIC INFECTIOUS DISEASES. 

or containinatcHl during collection) has caused septicaemia. Such 
accidents may he prevented by the use of calf lymph prepared with 
o'lycerinc. Erysipelas may ensue on vaccination under unfavorable 
circumstances. The vaccine vesicle, on about the tenth to the four- 
teenth day, instead of disappearing, may become the seat of deep 
numeration, owing probably to secondary inoculation under unfavor- 
able hygienic surroundings. All such sequelae are very rare. In a 
few instances syphilis has been inoculated with vaccinia ; in many 
more instances in which this has been supposed to have happened 
the syphilis from which the infant has suffered after vaccination has 
been congenital, and no case can be admitted to be an example of 
syphilis due to inoculation at vaccination unless a primary chancre 
be discoverable. 

[The glycerinated lymph is put up in sealed glass tubes and in 
this country is furnished by the city laboratory. It is prepared with 
great care, and is far superior to the old-fashioned '' points." Its 
more general use is greatly to be desired to prevent unnecessary in- 
fection. Strict antiseptic precautions should be taken in the vacci- 
nation, the physician's hands and patient's skin at the seat of the 
operation being made as nearly aseptic as possible. A sterile knife 
should be used for making the incisions and these should not be 
deep enough to draw blood. One incision is sufficient for an infant, 
two for a primary vaccination in a child under puberty, and three for 
any re-vaccination. The only dressing required is a piece of soft 
linen pinned or sewn to the inner side of the sleeve, or underdrawers 
when the vaccination is on the leg, to prevent rubbing or chafing of 
the aifected part.] 

The incubation period of small-pox is usually twelve days, not in- 
frequently a day more or a day less ; sometimes it is as short as nine 
days or as long as twenty. The period of observation should there- 
fore be three weeks. The infection is greatest during the height of 
the eruption. It is much less active during the initial stage so that 
the risk of infecting others may be diminished by isolating a patient 
at the beginning of the eruptive period : but all persons who have 
been exposed should be vaccinated (or re-vaccinated) and kept under 
observation. Infection remains until the scabs have cleared oif com- 
pletely. It may be carried by fomites (and preserved long in them) 
and in the clothes and hair of persons in attendance on a patient. 

The active agent of the infection is believed to be a small bacillus 
which has been shown by Klein and Copeman to be present in the 
lymph and the tissues about the pock about the fifth day in variola 
in man, and in vaccinia both in man and the calf. Before maturation 
it ceases to be discoverable, owing perhaps to the formation of spores. 

The on.sef, which is sudden, is marked by chilliness, or by convul- 
sions, which may be repeated several times during the stage of inva- 



SMALL-POX. 97 

sion. The temperature rises quickly to alnnit 104° F., and thnuioliout 
this stage the child suffers iVoni severe backache, licadachc, and ]iain 
in the limbs, and from nausea or vomiting. " Initial rashes," which 
occur in about one-sixth of all eases, usually appear on the second 
day, and commonly resemble, often very closely, those of measles or 
of scarlet fever. These rashes, however, are confined usually to the 
lower part of the abdomen, the axilhe, and the sides of the chest, or 
the extensor aspects of the limbs. Even in modified small-pox the 
symptoms during this stage may be very severe, but as a general 
rule they are proportionate to the subseciuent eru])tion ; that is, they 
are milder and longer lasting in cases in which the eruption is dis- 
crete ; shorter and more severe in confiuent small-pox. 

The eruption in discrete small-pox begins usually on the fourth 
day. On the forehead, near the margin of the hairy sc^ilp, and on 
the wrists, small, slightly elevated papules appear, and are very 
perceptible to the touch, owing to their firm, '' shotty " character. 
A little later they come out on the face, limbs, and scantily on the 
trunk. The eruption may affect also the mucous membrane (mouth, 
pharynx, larynx). In alx)ut forty-eight hours after its first a])iK'ar- 
ance each paj)ulc has become an umbilicatcd vesicle, and within it, 
in about forty-eight hours more (seventh to eighth day), supjniration 
has begun. The umbilication disappears, and the pustule thus 
formed is surrounded by an areola of red swollen skin. 

The temperature, which rises at the onset and attains its maxiniuiu 
(104° to 105° F.) during the second and third days of the stage of 
invasion, declines rapidly as the eruption comes out. A\'hen sup- 
puration begins, it rises again and remains elevated, with a morning 
fall and evening rise. During this stage of maturation the maxi- 
mum is touched on the ninth or tenth day, after which each evening 
rise is to a |K)int lower than on the previous day. This decline at- 
tends the drying of the i)ustules into scabs or crusts, which begin to 
be detached seven or eight days after the papules ai)peared (about 
the twelfth day of the disease). Sydenham's observation, that the 
danger to life is in proportion to the severity of the erupti(»n on the 
face, has been confirmeil by all experience. In the confluent form 
the papules, which api>ear early (third day), are very numerous on 
the face, and also on the hands and feet, and the vesicles and pustules 
run together into large blebs. The crusts are large, and ulceration 
is apt to occur Ixjneath them. The symptoms din*ing the stage of 
invasion are more severe, and the remission of temperature on the 
apjx-arance of the eruption is less marked ; during the stage of ma- 
turation it rises to 104° F., or higher, there is extreme restlessness 
or delirium, and r»ftcn diarrhoea. The eruption is usually present in 
the pharynx and larynx (so that the patient is hoarse), and often in 
in the mouth. The most usual cause of death is failure of the heart 



98 ACUTE SPECIFIC INFECTIOUS DISEASES. 

and collapse of the nervous system, evidenced by delirium giving 
^vav to coma. Of hsemorrhagic small-pox, which is rarer in children 
than in adults (of Osier's twenty-seven cases, three only were in 
children under ten) two types must be distinguished — (1) Purpura 
variolosa y a fulminating form of small-pox, in which the initial symp- 
toms are of great intensity. There is an initial purpuric rash, 
iKumorrhages into the conjunctivae and from the mucous surfaces, 
and death at an early date, often before the characteristic eruption 
appears. (2) Variola inistulosa hcemorrhagica, in which blood is 
effused into the vesicles or pustules, and bleeding may take place 
from mucous surfaces. The earlier the date at which the haemor- 
rhage begins, the worse the prognosis, and this form is very fatal. 
Cases occur, however, occasionally in which, during the vesicular 
stage, haemorrhage takes place into the pocks, but in which, never- 
theless, the course is favorable, the vesicles drying up and the dis- 
ease aborting. 

Varioloid, small-pox modified by vaccination, is seldom seen in 
early childhood, since children efficiently vaccinated, as a rule, 
escape infection altogether, the initial symptoms, usually compara- 
tively mild, though the pain in the head and back may be very dis- 
tressing, are sometimes severe, but the papular eruption is scanty, 
and with its appearance the temperature drops rapidly and does not 
again rise. Vesiculation and maturation are completed rapidly, and 
the patient enters on convalescence early. 

In childhood the most frequent and serious complications of small- 
pox are (1) broncho-pneumonia, which is a contributory cause of 
death in most fatal cases ; (2) laryngitis, which may cause death by 
producing oedema glottidis, ulceration of cartilages, or indirectly by 
blunting laryngeal sensibility, so that food is allowed to enter the 
air passages ; and (3) diarrhoea. Otitis media is a frequent secondary 
complication. Conjunctivitis, sometimes severe and purulent, lead- 
ing to keratitis and perforation, is not uncommon. 

Prognosis. — Unmodified small-pox is extremely fatal in young 
children, and few infants recover from it. Death, as a rule, occurs 
either in the early stage from the intensity of the disturbance of the 
nervous system or at the height of maturation, and is then usually 
hastened or determined by laryngitis or broncho-pneumonia. 

In the treatment of small-pox, precautions against the spread of 
the infection must be rigidly enforced (vide ante). For the relief of 
the severe backache and headache of the initial stage small doses of 
opium frequently repeated, or two or three doses of phenacetin, are 
useful. High fever may be treated by baths. Many remedies have 
been tried fi)r the ])revention of pitting, but Sydenham, one of the 
earliest, and Osier, one of most recent writers on the subject, agree 
that local remedies have no influence, or are actually injurious. 



VARICELLA. 99 

During the papular stage eokl, applied bv means of a face mask ke])t 
moist with water, to whieh an antiseptie (earbolie or perehloride) is 
added, is grateful to the patient, and probably tends to eheek the 
deepening of the poeks, and should be eontinued later, since it tends 
to cheek the formation of hard, dense crusts. When crusts have 
formed they should be kept constantly soft by the applicittion of 
vaseline, glycerine, or an ointment made with equal jiarts of hinoline 
and olive oil, to which some antiseptic, such as boric acid, should be 
added. The patient should have also one or two baths a day, for 
the removal of epithelial debris and crusts. The baths should be 
medicated with thymol, carbolic, or other antiseptic, and carbolic 
soap should be used. Stomatitis should be treated with antise})tic 
mouth washes and creams. The conjunctiviv shouhl be ins])ected, 
and on the signs of commencing inflammation should l)e thoroughly 
washed with antiseptic lotion three or four times a day, and if the 
eyelids are closed by swelling this precaution should be at once 
i adopted. For severe diarrho?a some preparation of opium, the tinc- 
. ture of paregoric in small doses frequently repeateil, should be used. 
' The theory that the pustular stage is rendered less severe and subse- 
quent pitting less deep by nursing the patient in a red light seems to be 
1 well grounded. It may l)e carried out by hanging the windows with 
I one thickness each of red and yellow photographic calico. 
I Varicella, a disease from which few children escape, is therefore 
seldom seen in adults. It is characterized by a vesicular eruption. 
The incul)ati()n period is usually fourteen days, but may be a day or 
' two less, or four or five days more. The disease is infectious as soon 
1 as the rash appears, and a convalescent patient may convey to others 
1 the infection, which is retained also in fomites. 

1 The disease is usually extremely mild. At the onset tlie patient 
, complains of malaise and chilliness, and there is a very slight eleva- 
j tion of temperature. The eruption usually begins within the first 
, twenty-four hours on the face and neck. It consists of scattered 
' papules, which in a few hours l>ecome converted into vesicles. The 
] vesicles are ovoid and not, as a rule, uml)ilicatcd. On the third or 

* fourth day they begin to shrivel, but before this the majority of them 
' have l)ecome purulent. The eruption often appears in distinct croj)s 

* upon the face, trunk, and limbs, so that those at tlic upper part may 
i already be scabbed while those on the limbs are vesicuLar. They 
' vary in number, from half a dozen to hundreds. As a rule, the scars 
1 left are very superficial ; but if the child is allowed to scratch in the 
' pustular stage, extensive ulceration, scabbing, and scarring may be 
( prmluced, and in marasniic children large ecthymatous |)at('lies, or 
' bullfe, may form. Occasionally ha'mf»rrliage takes place into the 
i vesicles, or into the surrounding skin, which is usually healthy ; or 

* blee<ling from the mucous membrane may occur. A rare complica- 

LofC 



100 ACUTE SPECIFIC INFECTIOUS DISEASES. 

turn is gangrene around the vesicles. The eruption may appear, 
usually at a very early stage, on the mucous membrane of the mouth 
(soft pahite, cheeks, gums) of the larynx, of the vulva, the conjunc- 
tiva, and in the external auditory meatus. In the mouth, where they 
are most often seen, the vesicles rupture early, leaving superficial 
circular erosions, with which may be associated severe stomatitis. 
Albuminuria is present during the fever in a small proportion of 
cases, sometimes persists for a fortnight, and is occasionally accom- 
panied by anasarca. Arthritis has been known to occur. 

The prognosis is good. Uncomplicated varicella is seldom or never 
fatal. Varicella gangrenosa is a serious disease, and in cases compli- 
cated by albuminuria may cause death. 

The diagnosis is usually easy, but cases occur occasionally which 
resemble variola, and the mistake has been made. The eruption in 
varicella, however, runs its course very rapidly ; redness, with at 
most very slight thickening of the spot of skin to be the seat of the 
vesicle, is succeeded in a few. hours by the effusion of clear liquid 
into the epidermis, forming a watery pock with a very thin wall. It 
does not involve the true skin, and if umbilication is to be observed, 
it is present only in a few vesicles. When, as is often the case, the 
vesicles are very numerous, the mildness of the general symptoms 
will put small-pox out of the question, and the slight character of the 
symptoms at the period of invasion w^ill afford corroborative evidence, 
for it will be remembered that even in modified small-pox the initial 
symptoms are usually severe. Impetigo has been mistaken for vari- 
cella, but a close examination of the lesions and of their mode of 
development will prevent such an error. Rather more difficulty may 
be experienced in distinguishing pemphigus from varicella, but the 
course of the disease will quickly clear up any doubt. 

The treatment must be conducted on general principles. The 
child should be kept in bed until the temperature has fallen. Scar- 
ring seldom occurs if attention be paid to cleanliness and to the pre- 
vention of scratching, which may lead to the inoculation of the ves- 
icles with pyogenic organisms. A mild antiseptic, such as boracic 
ointment, is to be recommended as an application to any pocks which 
show a tendency to suppurate. 
y Measles is an acute infectious fever, characterized by a prolonged 
stage of })rodromal catarrh and a peculiar eruption. 

The interval between exposure to infection and the appearance of 
the rash is usually fourteen days, or one day more or less, but it may 
be as long as eighteen or as short as seven days. The infection is 
very active during the primary stage ; that is, for three or four days 
before the rash appears, and probably not less so during the whole 
acute attack. It diminishes rapidly during convalescence, and has 
ceased at the end of three weeks from the appearance of the rash. 



II 



PLATE 



Fig. 1, 



Fig. II. 





Fig. III. 



Fig. IV. 





The Pathognomonic Sign of Measles (Koplik's Spotsj. 



( 



Fig. I. — The discrete measles spots on the buccal or labial mucous membrane, showing the isolated rose- 
red spot, with the minute bluish-white centre, on the normally colored mucous membrane. 

Fif.. 2. — Shows the partially diffuse eruption on the mucous membrane of the cheeks and lips ; patches 
of pale pink interspersed among rose-red patches, the latter showing numerous pale bluish-white spots. 

Fig. 3. — The appearance of the buccal or labial mucous membrane when the measles spots completely 
coalesce and give a diffuse redness, with the myriads of bluish-white specks. The exanthema on the skin is 
at this time generally fully developed. 

Fig, 4. — Aphthous stomatitis apt to be mistaken for measles spots. Mucous membrane normal in hue. 
Minute yello-v points are surrounded by a red area. Always discrete. 



MEASLES. 101 

It may be conveyed by fomitos. AVhen inoculated the incubation 
period is less than ten days. 

The severity of measles varies in ditlerent ejiidoniies, but uiore 
important factors are : (1) the general hygienic surroundings of tlie 
patient — when these are bad the chance of a severe attack is in- 
creased ; and [2) the age of tlie patient — the death-rate is very high 
(even over 50 per cent, in some epidemics) in children un<ler two 
years old. It is still high from two to four years, but declines 
rapidly after that age. Canon and Pielicke have described a small 
bacillus as present in the blood in measles, and their results a]>})car 
to be confirmed by Czajkowski, who fouud a similar bacillus in the 
blood of fifty-six cases examined for this purpose.^ 

The prodromal, primary, or catarrhal stage endures usually l)c- 
tween three and four days ; it may be very much shorter, even only 
a few hours, and is extended occasionally to seven or eight days. 
The child is chilly, loses appetite, and begins to suffer from coryza 
and photophobia. Complaint is made often of headache and, within 
the first day usually, cough becomes troublesome. The tongue is 
furred, the pharynx hyperaemic, the soft palate sometimes covered by 
a punctiform rash. [An eruption also appears on the l)uccal mucous 
membrane, regarded by Koplik as pathognomonic of beginning mea- 
sles. This eruption, called tlje enantheni, appears very early, before 
the exanthem, is seen on the buccal mucous membrane and inside of 
the lips, consists of small irregular spots of a bright red color in the 
centre of which is noted in strong daylight a minute bluish-white 
gpeck. Koplik regards it of the greatest diagnostic value early in 
the disease before the appearance of the skin eruption. Plate I.] 
The temperature rises rapidly, attaining 103° to 104° F. on the first 
day ; it then falls 1° or 2°, but rises again on the fourth day just 
before the rash appears. This usually comes out rapidly often dur- 
ing the night, atfecting first the cheeks, forehead, and the skin be- 
hind the ears ; then the neck, the trunk, and, lastly, the limbs. The 
rash consists of discrete p:i))ules, which enlarge, increase in number, 
and become arranged in crescentic patches. The characteristics of 
the rash are best seen on the face and neck. In these parts the 
patches have a dusky or purple tinge, are distinctly raised and hard, 
and are attended by more or less o?dema of the surrounding skin. 
Miliary vesicles often form, and petechia? may ap])car even in mild 
cases. In malignant cases there may be a good deal of hjemorrhagc 
into the spots. On the trunk the rash is often less distinctly jiapular, 
and may be no more than a dusky mottling. The rash continues to 
spread for twenty-four or forty-eight hours, or a little longer, and 
during this time the temperature remains high, reaching j>erhaps 
104..')^ F. on the second day of the rash. The coryza, coulHi. pho- 
' C^nt.f. Bakt. u. Par., Band xviii., Num. 17, 18. 



102 ACUTE SPECIFIC INFECTIOUS BISEASES. 

tophobia, and other general symptoms remain severe for about the 
same period. The rash in each region begins to fade in about thirty- 
six hours, so that it may be disappearing on the face while still com- 
ing out on the limbs. If there be no complication all the symptoms 
begin to improve so soon as the rash ceases to extend. The temper- 
ature falls rapidly, though not as a rule by a distinct crisis, and 
reaches normal on the seventh or eighth day from the commencement 
of the illness. The rash is attended by a good deal of hypersemia, 
so that the color can be almost completely discharged when at its 
height, but a slight yellow stain may remain after the rash has faded. 
Fine branny desquamation, most marked on the trunk and lower 
extremities, but often very inconspicuous, follows after the disappear- 
ance of the rash. 

The most important complications are those of the respiratory sys- 
tem. Bronchitis, which is rather a symptom than a complication, 
predisposes to the occurrence of broncho-pneumonia in the manner 
indicated in the chapter on this disease. This complication is re- 
sponsible for the greater part of the high death-rate. Lobar pneu- 
monia is less common, but the specific poison of measles appears to 
be able to produce a special form. Laryngitis, frequent in some 
epidemics, may cause oedema of the glottis. [It may be membranous 
and, developing at the height of the disease, is generally due to the 
streptococcus ; but when it develops at a later period, it is usually 
due to the diphtheria bacillus. Holt states that it occurs more fre- 
quently as a complication of measles than of scarlet fever, and that 
as a cause of death in older children, it ranks next to pneumonia.] 
Stomatitis, which may lead to severe ulceration, or cancrum oris may 
occur in debilitated infants, as may also ulcerative vulvitis. Otitis 
media, Avhich is secondary to pharyngitis, is a common complication 
and may lead to mastoid suppuration, to perforation, and to perma- 
nent loss or dulling of the sense of hearing. Conjunctival catarrh 
occasionally runs on into suppuration, and tinea ciliaris is a not un- 
common sequel. Severe diarrhoea, due in many cases, at least, to 
membranous colitis, occurs very frequently in certain epidemics, and 
may be attended by intestinal haemorrhage. Nephritis is a rare com- 
plication. Various affections of the nervous system, which are de- 
scribed elsewhere, occur in rare cases. 

The diagnosis of measles in a well-marked case is easy, owing to 
the special course of the symptoms and characters of the rash. Occa- 
sionally, when the throat symptoms are severe and the eruption more 
diffuse and less papular than usual, there may be a considerable re- 
semblance to scarlet fever. But the history of the case, the long 
primary stage, and a careful inspection of the rash will generally 
prevent error. The prodromal rash of small-pox may resemble 
closely that of measles in an early stage, but in the latter the papules 



RUBELLA. 103 

svhicli shortly appear arc less shotty, and the accompanying symptoms 
of catarrh ditter from those usually observed in small-pox. Tlie 
diagnosis from rubella, which may be extremely difficult in a single 
case, is discussed under that disease. Acute dermatitis occasionally 
causes some hesitation, but the history of the case and a careful in- 
spection of the eruption, which commonly presents })ustulai- points 
and scabs and runs a more chronic course with less fever, will jire- 
vent mistakes. 

The prognosis depends almost entirely upon the nature and severity 
oi the complications, the large death-rate which measles produces 
being due in the main to pulmonary complications. High temj)er- 
ature is not necessarily a bad omen ; on the contrary, the woret 
cases are seen in debilitated children who pass into a condition of 
great depression, attended by haemorrhage into the rash, without high 
pyrexia and, it may be, with normal or subnormal temperature. 
The existence of chronic tuberculosis is an unfavorable element in 
prognosis, since an attack of measles may determine a rapid exten- 
sion. 

The treatment of measles in mild cases does not call for active 
measures. The child should be kept in bed from the time the tem- 
perature rises until four or hve days after the pyrexia has ceased. 
The room should be shaded to diminish the distress caused by the 
photophobia, but not kept too dark. The food should be light, con- 
sisting of diluted milk, vegetable soups, and meal gruels. As a rule, 
pyrexia does not call for any direct treatment, but, when high, it 
may be reduced by the wet pack with water at 85° F. The pro- 
phylaxis of broncho-pneumonia is, in reality, the most important 
part of treatment, and in this cleanliness and ventilation are of tlie 
first im}X)rtance. For the constipation, which often exists at the 
beginning of the disease, mild laxatives only, such as castor oil or 
liquorice p<»wder, should be given, since purgatives tend to produce 
I the intestinal catarrh or meml)ranous colitis, which ccmstitutes one 
of the dangers of the disease. Great care should be exercised dur- 
I ing convalescence, both in diet and in guarding the child from chill, 
! though it should be given the advantage of outdoor air as early as 
! the woather permits. 

kj^ Rubella, or German measles, is an acute, specific, infectious, 
I eruptive fever, which resembles a mild attack sometimes of measles, 
j at other times scarlet fever. As a rule, it is a very mild disease, 
I and is, indeed, chiefly of importance because it is liable to lead to 
' mistakes in diagnosis. 

I The incubation period is long, seventeen or eighteen days as a 

nile ; but it may be two or three days moro, or five or six days less. 

' The patient is infectious for some days l>efore the a})pcarance of the 

! rash, but not for long after its disappearance. Infection is over 



104 ACUTE SPECIFIC INFECTIOUS DISEASES. 

within throe weeks after the beginning of the attack. The time for 
whicli a susceptible person, who has been exposed to infection, must 
be kei)t under obsercafion before it can be asserted that he has es- 
caped the disease is three weeks, and at the end of this time he must 
be found free from rash, sore tliroat, or glandular enlargement. 

Often the first symptom to attract attention is the rash. In other 
cases its appearance is preceded for from twelve hours to two or 
three days by malaise, headache, suffusion of the eyes, soreness of 
the throat, pain in the back, and glandular enlargement. The rash 
is seldom delayed beyond the second day. It appears first behind 
the ears and round the mouth and nose ; it spreads thence, often 
very rapidly, but sometimes in successive crops, to the trunk and 
limbs. At first it consists of slightly raised, rosy-red spots, scat- 
tered over the healthy skin ; the spots are smaller and more discrete 
than those of measles, larger and more papular than those of scarla- 
tina. In some cases — those which constitute the scarlatiniform 
class — the character of the rash changes after a few hours. On the 
face it is obscured by a bright red flush, while the limbs become 
covered by a fine, punctate rash, identical with that of scarlatina. 
The rash, whether morbilliform or scarlatiniform, reaches its maxi- 
mum in any area in about twelve hours, and then begins rapidly to 
fade. It is all gone by the third day, as a rule. [Coincidentally 
with the appearance of the exanthem is observed the enanthem, dif- 
ferent, however, from that of measles, described above. According 
to Forchheimer this enanthem is the same eruption that is found on 
the skin, is of a pure pinky rose red, and is localized upon the uvula 
and soft palate, rarely invading the hard palate. It is short-lived, 
fading away within the first twenty-four hours.] The general 
symptoms, Avhich are usually very mild, are coincident with the rash. 
The temperature rises, as the rash comes out, to perhaps 100° or 
101° F. It remains at about this level, or perhaps touches 102° 
F. on the evening of one or two days while the rash is out, and falls 
to normal as the rash fades. The pulse increases in frequency as 
the temperature rises, and decreases as it declines. The eyes are red 
and watery, but, usually, there is no photophobia ; there is a general 
redness of the palate and fauces, and often enlargement of the tonsils 
and some dysphagia. Cough, which is often troublesome, is gener- 
ally dry and ineffectual, and only occasionally are there signs of 
bronchitis. The patient, as a rule, does not feel ill, and when first 
seen will often be found running about, retaining his appetite and 
taking only a curious interest in his rash. The most characteristic 
symptom is a general enlargement of the glands ; this may precede 
by three or four days the appearance of the rash, and may continue 
for a week or more after it has faded. The glands enlarged are 
those at the back of the neck, beneath the ear, and under the sterno- 



RUBELLA. 105 

mastoid muscles ; more rarely, those in the axilhv ami Liroin. Thev 
are hard and tender, though, as a rule, the })atient makes no com- 
plaint of them. Convalescence begins as tlie rash fades, and is gen- 
erally rapid. Desquamation occurs in a large proportion of the 
cases ; it is often scanty, and to be detected oidy by careful exami- 
nation of parts of the body, such as thesub-chivieuhir region.^ which 
are not much exposed to friction. It is commonly more copious in 
those cases in which the rash most resembles that of scarlet fever, 
but it is always fine and branny, and even on the hands and feet the 
ejMthelium is not detached in flakes. Com])lications rarely arise. 
The throat affection may be severe, and a friable or pultaceous false 
membrane has been known to occur on the tonsils. The bronchtis 
which sometimes accompanies the rash may be severe, and may thien 
persist after the rash fades. Broncho-pneumonia and ])leuro-pneu- 
monia have been known to supervene. Laryngitis may occur, but 
is seldom or never serious. The pharyngeal catarrh may cause ob- 
struction of the Eustachian tube and pain in the ear. Relapse after 
j an interval of a few days or two or three weeks has hvcu observed. 
• The prognosis is good ; in cachectic children already suffering from 
some chronic wastinor disorder, an attack of ru])clla mav hasten or 
; determine a fatal issue, or may leave chronic tonsillitis or naso- 
, pharyngeal catarrh or chronic adenitis. As a rule, recovery is rapid 
and complete. 

Aberrnnf tyi>es are described. It is probable that the disease may 

occur without rash. In some cases suffusion of the conjunctiva, 

" pink eye," with slight feverishness, may be the only symj)tom, 

and })robably some of the cases of widespread enlargement of the 

lymphatic glands, with slight feverishness, in children are examples 

of rubella without the rash. Epidemics of a rose nisji, a pa])ular 

eruption without catarrh and with little or no fever, occur sometimes 

in summer, and are generally classed as mild rubella. They are 

' probably due to some different infection, which does not protect from 

rubella. This rose rash consists of large rounded areas of bright 

red, closely set spots, sciircely raised, which appear suddenly without 

I prodromal symptoms on the neck, limbs, and trunk. Tiie face often 

' escapes. The rash fades in about thirty-six hours, and the ])yrexia 

i (if there has been any) ceases with it. The fauces may be a little 

! reddened, but there is no complaint of sore throat and no enlarge- 

' ment of glands. 

I The treatment of an f>rdinary case of rubella should consist merely 

' of keeping the child in bed or in a warm room for four or five days, 

and indwjrs for three days more. It sluudd then be given as much 

fresh, outdof>r air as possible for a week, and a series of disinfecting 

I baths. The diet should be light during the j)yrexia, and it is well 

to give a dose of laxative medicine at tlie onset of the disease. 



106 ACUTE SPECIFIC INFECTIOUS DISEASES. 

The diagnosis from measles or from scarlet fever may often be — 
at any rate at first — extremely difficult, if not impossible. The 
Medical Officers of Schools Association admit that ^' In some cases 
the eruption may so closely resemble that of either measles or scar- 
latina in local appearance that a diagnosis founded on the eruption 
alone is impossible.'^ Probably the most distinctive feature is the 
early and general glandular enlargement. The mild type of the 
catarrh, the absence of photophobia, and the change in the character 
of the eruption when this occurs, will assist in the discrimination 
from measles ; while the absence of the thick white fur on the tongue, 
which peels off from the tip and edges on the fourth day, leaving a 
raw, red surface, the general absence of albuminuria, and the duskier 
red of the eruption, Avill help to distinguish the cases from scarlet 
fever ; at a later stage the character of the desquamation will give 
valuable evidence. Children seldom show much change of temper 
with rubella, whereas they are generally irritable and depressed with 
measles, and feel very ill with scarlet fever, except in the mildest 
attacks. In arriving at a decision, all the circumstances of the case 
must be taken into consideration, but too much weight must not be 
attached to a previous history of measles or scarlet fever, especially 
if the diagnosis rests merely on maternal authority. The table on 
the next page contains a list of the points to which attention may 
specially be directed. 
^ In scarlet fever the incubation period is short — ^usually from 
twenty-four to seventy-two hours. It may be shorter, or may ex- 
tend to four, five, or seven days. Scarlet fever is infectious from 
the onset of the earliest symptoms and until long after convalescence 
has been established. Infection may persist certainly as long as 
desquamation, so that it may still be active eight weeks after the 
onset. Infection is readily preserved and conveyed by fomites. A 
susceptible child who has been exposed to the infection must not be 
assumed to have escaped unless on the eighth day he is free from 
fever and sore throat. 

The onset is rapid, often extremely sudden. It is attended com- 
monly by vomiting, in young children by convulsions, and the tem- 
perature is then found to be elevated. The skin is red, pungently 
hot to the touch, the tongue is furred, and the throat dry. The 7^ash 
appears usually within twenty -four hours of the first symptoms. At 
first a streaky redness of the neck and chest, upon which are situated 
closely scattered red points, it spreads rapidly, and when fully de- 
veloped the whole surface of the body is of a vivid scarlet tint, 
though occasionally areas of normal color may remain. The face is 
usually spared, and the rash, if present, is confined to the forehead 
and temples, the cheeks being merely flushed. Sudamina frequently 
occur, and may be very numerous, and occasionally there are petechiae. 



SCARLET FEVER. 



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108 ACUTE SPECIFIC INFECTIOUS DISEASES. 

After about two days the rash commences to fade. The tongue is at 
first furred in the centre and red at the tip and edges, the enlarged 
papillte showing through the fur as red points (strawberry tongue). 
As the rash subsides the tongue cleans, leaving a red, rough surface 
(raspberry tongue). The pharyngeal symptoms vary greatly. In 
some cases there is merely a red mottling, which appears about the 
same time as the rash. In others, one of the earliest symptoms is 
severe follicular tonsillitis, which may lead to sloughing of the ton- 
sils. In others, again, the inflammation is more diffuse, affecting all 
the pharyngeal structures, and leading to secondary adenitis and to 
ulceration, which may be so deep as to open into the carotid. The 
adenitis at this stage is proportionate to the extent and degree of the 
local lesion. 

The course of the temperature in a typical case is as follows : — 
After the sudden rise at the onset there is a slight remission, followed 
by a second rise, reaching a maximum of 103° to 105° F. on the 
second or third day ; thereafter there are morning remissions and 
evening exacerbations for four or five days, the normal temperature 
being reached on the eighth or ninth day. Febrile albuminuria is 
frequent, but disappears as the temperature declines. After the dis- 
appearance of the rash the skin becomes harsh and dry, and des- 
quamation commences usually on the forehead and neck. The epi- 
dermis is detached in large scales, which upon the fingers may be so 
large as to resemble the fingers of a glove. The hair falls out, and 
may even be lost entirely. Desquamation is usually over in from 
ten to twenty days, but may last much longer, and a second and even 
third desquamation may occur. 

The severity of scarlet fever varies very greatly. In some cases 
it is extremely mild, and the diagnosis can only be made owing to 
the simultaneous occurrence of other cases, or the subsequent occur- 
rence of cases infected from the mild case. In others the disease 
sets in with delirium, headache, high fever, and even hyperpyrexia. 
Great prostration rapidly ensues, with dyspnoea and a rapid feeble 
pulse, and the patient becomes comatose. Occasionally, especially 
in debilitated children, the rash is accompanied by petechise and 
haemorrhage from the nose or kidneys ; prostration is great, and the 
result is usually fatal. 

At an early stage the most frequent complication is otitis media, 
which arises in connection with the throat lesions. Membranous 
pharyngitis and laryngitis are observed in a considerable proportion 
of the more severe cases, but as a rule this membrane is really 
diphtherial. Scarlatinal nephritis is the most characteristic sequela. 
It begins usually in the second or third week, but may be delayed 
until the fourth or fifth. It varies very greatly in severity, and may 
come on after a mild attack. It is discussed elsewhere. Occasion- 



SCARLET FEVER. 109 

ally c^tlema without allniininuria, duo in most cases prohaMy to 
anaemia, is observed. Both pericarditis and endocarditis niav occur, 
but the latter is often unrecoirnized durino- the icvcr, and onlv irives 
rise to symptoms some months later. Arthritis affecting sometimes 
many joints is an occasional complication, observed usually as the 
fever subsides, but occasionally at an early date contemjx.raneous 
with the initial tonsillitis. It is in some cases associated with peri- 
carditis ; recovery without permanent injury to the joints is the rule. 
Arthritis commencing at a late date, and limited to one or two large 
joints, is more apt to end in suppuration. Mahomed believed thai 
the interval from the eighteenth to the twenty-second day was a kind 
of critical period during which there was a rise of arterial tension, 
diminished excretion of urine and urea, and rise of temperature, 
with a corresponding liability to complications — albuminuria, otor- 
rha\a, diarrhcea, and cervical adenitis (piite out of proportion to any 
local phaiyngeal lesion remaining. At about the same period sec- 
ondary rashes are met with in 2 or 3 per cent, of all cases, but 
rather moiT frequently in children under five years (4.8 per cent.).' 
Erythematous, urticarial, and purpuric rashes are most often seen in 
cases complicated by arthritis ; papular and eczematous rashes are 
also met with at alx)ut this period, and are probably, in many in- 
stances, due to septicaemia. 

Pulmonar}- complications are, on the whole, uncommon, but in some 
epidemics l)roncho-pneumonia occurs in a large pro})ortion of the cases, 
and occasionally pleurisy, which is usually purulent. Of the nervous 
complications the most common is chorea, which is seen most often as a 
sequel to those cases in which arthritis and heart disease have occurred. 

The diagnosis of scarlet fever is usually easy. The errors which 
occur are rather in the direction of mistaking other conditions for it 
than of overlooking the disease itself. Acute exfoliative dermatitis, 
which may come on suddenly, with fever and a rapidly-spreading 
en'thematous rash, cannot always be distinguished with certainty in 
the earliest stage from scarlet fever; but even when doubt exists, 
owing to the absence of throat symptoms, it is prudent io treat the 
case as though it were certainly scarlet fever. The cases classed as 
eri'thema scarlatiniformc are discussed elsewhere. The resemblance 
of rubella in one of its forms to scarlet fever is sometimes very close, 
as is mentioned elsewhere. The rash produced by septicaemia may 
be identical with that of scarlet fever. The throat symptoms are 
usually absent or slight, but as operation or injury predisiwses a child 
to contract sr?irlet fever, the management of cases in which any doubt 
arises should be founded upon the assumption that the disease may 
be scarlet fever. 

> Manning', LfmM^ 1892, ii., p. 3r,3 ; (Jonf. Caiger, iln>l., I'-Ol, i., 1*-'1'.«; and 
Symea, BruOA Med. Chi. Journ., March, 1897. 



110 ACUTE SPECIFIC INFECTIOUS DISEASES 

Membranous laryngitis, coming on after the third or fourth day, is 
usually due to diphtheria, but earlier than this, especially if the 
membrane is thin and white, it is probably due to streptococcus-in- 
fection. The rash produced by belladonna has been mistaken for 
that of scarlet fever, as have also those produced, more rarely, by 
quinine and potassium iodide. The absence of fever, the condition 
of the throat — which in belladonna poisoning is red and dry, but not 
inflamed — and the general circumstances of the case will prevent 
mistake being made. 

There is considerable difference in prognosis in different epidemics. 
Unfavorable symptoms are : fever which is very high or continuous, 
severe nervous symptoms, haemorrhages, or extensive angina with 
adenitis. The mortality is higher the younger the child. A 
moderate amount of albumen in the urine in an early stage is not a 
serious symptom, and its danger in convalescence is in proportion to 
the rapidity with which it develops. 

The treatment in mild cases consists mainly in attending to the 
comfort of the patient and warding off complications. The child 
should be isolated in a well-ventilated room, and should be given a 
limited light diet, consisting of diluted milk and gruels, and allowed 
to drink freely of water, which may be acidulated. Sponging with 
warm water two or three times a day, and, when desquamation be- 
gins, a warm bath with superfatted soap should be given daily. 
Very good results are claimed ^ for the systematic use of warm baths, 
twice a day for the first week, and then daily. Each bath lasts ten 
minutes. The liability to nephritis, it is maintained, is thus dimin- 
ished, owing to the baths favoring the removal of the poison which 
is assumed to be eliminated by the skin. The course of the disease 
is rendered milder, and desquamation during convalescence is slight, 
owing to the gradual removal of the desquamating epidermis by the 
baths. The use of oils and ointments for the skin is of doubtful ad- 
vantage to the patient, and, when isolation can be effectually carried 
out, is unnecessary in the interests of others. Very high temperature, 
accompanied by delirium or collapse, should be treated by cold 
sponging, or by a cold or lukewarm pack. When, on the second or 
third day, the temperature is found to be rising rapidly, a warm bath, 
cooled to 80° or 85° F., will check the rise and relieve the attend- 
ant symptoms. It may be combined with or replaced by the use of 
the ice-cap. The throat symptoms will be relieved by cold drinks 
or small pieces of ice to suck, and by cold compresses or hot fomenta- 
tions externally. Local astringent applications, such as glycerine of 
tannin or pulverizations of resorcin, should be used also, and, when 
ulceration has commenced, insufflation of boric acid in powder, and 
the local application of a strong solution of nitrate of silver or of 
^ Schill, Jahrb. f. Kinderhlkde, Bd. xliii. , s. 260. 



SCARLET FEVER. Ill 

chloride of zinc to the part are to be advised. The oeeurrenee of 
seeondarv rash at or about the end of the third week should be taken 
as an indication that the onset of other eoniplieations is not improb- 
able. In the hope of preventing nephritis, or diminishing its 
severity, the patient should be sent back to bed, placed on a very 
bland diet (milk), and given a dose of calomel followed by acid tar- 
trate of potash. 

[Bacteriology. — Class of Chicago believes he has discovered tlie 
specific organism of scarlet fever. He describes it as follows : a 
diplococcus resembling a very large gonococcus, gnnving best on a 
medium made of glycerin-agar and garden earth, and stained by a 
number of the aniline dyes. 

Pearce has studied the bacteriology of many complications of 
scarlet fever and states that the micro-organisms producing secondary 
inflammatory lesions are the streptococcus }>yogenes, the staphylo- 
coccus pyogenes aureus and the pneumococcus. He considers that in- 
fections of the middle ear, antra of High more and of the sphenoidal 
sinuses are of the utmost practical importance and apt to be the 
starting point of chronic trouble.] 



CHAPTER VII. 
ACUTE SPECIFIC INFECTIOUS DISEASES (eontinued). 

Influenza — Whooping-cough — Mumps — Glandular Fever — Cerebro-spinal Meningitis 
— Enteric Fever. 

Influenza, an acute infections disease spread almost solely by 
personal intercourse, and due, in all probability, to the specified 
bacillus described by Pfeiffer and Kitisato, affects children in many 
epidemics in about the same proportion as adults. Infants at the 
breast enjoy a certain immunity, but it is less marked than in many 
other diseases of this class. In England and Wales in 1890 the 
deaths from influenza per 1,000 living at different ages were : ^ for 
all ages, males 0.17, females 0.14; at ages 0-5 years, males 0.16, 
females 0.12 ; at ages 5-10 and 10-15, males 0.02, females 0.03. 

The various clinical types described as occurring in adults may also 
be observed hi children, but in them a large proportion of all cases 
in most epidemics are of the simple febrile type; that is to say, 
pyrexia without any definite signs or symptoms referable to any one 
organ or system. The onset of the fever is usually very sudden, and 
the thermometer often attains 105° to 106° F. in a few hours ; the 
skin is flushed and moist, and the child is usually drowsy. Occasion- 
ally somnolence is very marked, so that the child cannot be aroused. 
In those cases in Avhich the temperature rises to the height mentioned 
defervescence occurs usually in about twenty-four hours or even less, 
and after a few days of languor the health is completely restored. 
In other cases, especially those in which the onset is less sudden and 
the initial rise of temperature less high, the pyrexia continues for 
two, three, or four days, and convalescence is more prolonged. 
Allied to this type are those cases in which nervous symptoms are 
marked ; the patient, if an infant, is restless and cries out occasion- 
ally, and in older children complaint is made of neuralgic pains, some- 
times referred to the joints and then called rheumatic. In infants 
convulsions sometimes occur ; in older children vomiting ; and at 
both ages somnolence is occasionally very marked, and causes much 
alarm to the friends. The catarrhal type is also observed with great 
frequency. The catarrh affects all the respiratory passages and the 

^H. Franklin Parsons, "Further Report (to the Local Government Board) and 
papers on Epidemic Influenza," 1889-92. 

112 



INFLUENZA. 113 

conjunctivae, so tliat tlie aspect of the jiatient recalls the onset ol' 
measles. In other cases the hiieeal niueoiis niemhrane is that most 
severely aliected, anil small circular ulcerations are often t>l)serve(l. 
In other cases, again, the general symptoms — tlushed face, moving 
ahv nasi, ami rapid breathing — suggest pneumonia, but the physical 
signs are those of slight bronchitis only, autl the dyspncva is ])n)bal>ly 
due, in the main, to toxa^nia. Occasicnially the signs of laryngitis 
are marked, the voice is hoarse, and attacks of stridulous breathing 
occur, during which there is marked recession of the bases of the 
chest. These symptoms may persist without much change for 
several days, and then disappear rapidly. Convalescence from the 
catarrhal form is usually more prolonged than from the simple febrile 
form, and frecpicntly detiuite bronchitis develops, and sometimes 
, broncho-pneumonia. The gaj^tro-infestinal type is perhaps less com- 
mon in infancy and childhood than might have been expected, judg- 
, ing from the liability of children to such alfcctions. Soon after the 
; onset of the fever the child begins to vomit, and the tongue is seen 
, to \yQ covered with a thick white fur, or is red and irritable, with 
j enlarged papilhw Diarrhcnea, the stools containing usually much 
mucus, comes on, and the patient loses flesh rapidly. After three or 
, four days the diarrhoea tends to diminish, but some looseness of the 
, bowels often persists for several weeks, and the strength and flesh are 
I regained slowly. In some cases belonging to this ty|)e the symptoms 
are very severe ; the temj)erature is high ; the child cries with pain 
r in the belly, and is drowsy or somnolent ; the hands and tongue are 
• tremulous ; and the whole aspect recalls typhoid fever. In some 
, there is diarrhrea, in others constipation. In others, again, the ty- 
. phoidal condition becomes established more slowly after an ordinary 
milk attack of the gastro-intestinal form. In cases having this char- 
; acter the symptoms may persist for a fortnight or more. 

The most common and serious Complication is broncho-pneumonia. 
( It occurs most often in cases of the catarrhal type but may complicat** 
any form. It may present no symptoms which in any way distinguish 
, it from ordinary, so-called j)rimary, broncho-pneumonia ; or the tcm- 
I perature, dyspnoea, and general distress maybe out of proj^ortion to 
I the physical signs at any time to l)e detected ; or it may from the first 
I be of a |X'culiar depressed tyj>c, which has been well described by 
I Ferrcira.' In these most characteristic forms the temperature is little 
' if at all raised, cough is not troublesome, and the patient, usually a 
I child unfler two years of age, is listless and drowsy. Dyspncca is 
« severe, the face dusky, the resi)iration hurried, with recession of tiic 
( chest walls in their lower part and under th<' elavieles. 'I'Ih' whole 
I course of the ca.se is prolonged and the symptoms throughout of 
' "Sthenic type. Pulmonary collapse is ver}' apt to oemr uw] t<» be 
'Ra-. d. MnL (h r Enf., 1895, p. 105. 



114 ACUTE SPECIFIC INFECTIOUS DISEASES. 

the determining cause of death, which is the termination of a large 
j)roportion of such cases. Pneumonia, lobar in distribution, also 
occurs as a complication, but less often than in the adult. Pleuro- 
pneumonia is a not uncommon complication in some epidemics, and 
may be followed by empyema. [Otitis Media is also a frequent com- 
plication of influenza. Nephritis occurs not uncommonly and re- 
peated examinations of the urine should be made.] 

The diagnosis of influenza, unless an epidemic is known to exist, 
is often very difficult. [It may often be determined by bacteriolog- 
ical examination of cultures taken from the mouth and throat show- 
ing Pfeiffer's bacillus.] During epidemic periods the febrile form is 
sufficiently characteristic, especially if accompanied by somnolence. 
The resemblance of the severer types of the gastro-intestinal form to 
typhoid is considerable, but the exanthem is absent.^ The flushing 
which commonly attends the onset of influenza may be so intense as 
to amount to erythema and later on may be followed by desquama- 
tion, so that a considerable resemblance to scarlet fever is presented. 
In other cases the erythema is patchy and presents some similarity 
to that of measles. The diagnosis of such cases must depend partly 
on a careful examination of the rash, which resembles, but is not 
identical with, that of scarlet fever, and on the general circumstances 
of the case. Tonsillitis is sometimes severe, and may increase greatly 
the difficulty of diagnosis, but such a combination is rare. The re- 
semblance to the rash of measles is generally very superficial, and 
the date of appearance of the rash does not coincide with the epoch 
at which it appears in measles. 

The prognosis in children over three or four years of age is very 
good, the main danger being from the severity of the broncho-pneu- 
monia when it complicates the malady. In younger children the 
prognosis is also good, except when the patient is already rickety or 
" scrofulous'^; in the one, broncho-pneumonia, if it occur, is a seri- 
ous disorder, as is always the case in rickety children, and has a 
prognosis of its own ; in the other, the inflammatory affections of the 
air passages, which attend influenza and are always associated Avith 
more or less enlargement of the lymphatic glands, may determine 
severe adenitis, and even light up acute tuberculosis. In infants 
who are, comparatively, seldom aifected, influenza is often severe, the 
nervous depression being very marked and the mortality higher than 
at other ages of childhood. After an attack of influenza, at any age, 
which has been complicated by broncho-pneumonia or much gastro- 
intestinal disturbance, convalescence is often prolonged, and the child 
suffers from anajmia, loss of appetite, and languor. Tuberculosis is 
an occasional sequel. 

' The diazo-reaction is not obtainable. The typhoid serum reaction will also, doubt- 
less, be of use in the future. 



WHOOPryCr-co ugh. 1 15 

Prophylaxis is not easy. The iiieubation period is two or three 
(lays, as a rule, ami a patient heiiins to he inteetiuus eertainlv within 
the first twenty-four hours, and so eontinues tor eight or ten days, 
probably therefore after he has beeome suftieiently etMivalescent to 
resume his ordinary avocations. Children residing in the ct^untry 
and much out of doors are more likely to esca}x\ or if thev eoi^tract 
the disease to suffer from a milder attack, than those in towns and 
under unfavorable hygienic conditions (especiallv overcrowding). 
The first member to be attacked in a household is commonlv an 
adult, usually the father, and immediate removal of the cliildren 
often serves to save them from the infectl«^n. An infant at the breast 
may escape, even though the mother sutlers. AVhen a chihl has been 
attacked, attention to the cleanliness of the mouth and pliarynx, and 
to the ventilation of the room in which it is nursed, will diminish the 
risk «tf ]Hilm<^narv comjilications. 

The treatment of influenza should be as simple as possil)le. Tlie 
patient should be. kept in bed, given li(|uid nourishment and demul- 
cent drinks to appease the thii*st, which is often troublesome. De- 
pressing antipyretic drugs should be avoided, as the danger in almost 
all cases lies not in the fever Init in the accompanying or se(jU(Mit 
nervous depression. (Quinine, whieh has been much used, especially 
'in the form of the ammoniated tincture, is at least harmless, and 
sodium salicylate is of some value, esi^ecially in cases in Avhich there 
are neuralgic or arthritic pains. Broncho-pneumonia and diarrha^a 
'must be treated on ordinary principles. Restlessness and excitement 
may be treated by phenacetin, of which as much as gr. j may be 
given every four hours at one year of age. The warm pack, if the 
|>erature be moderate, or the cold pack if it l)e very high, has 
a very soothing effect. The most important part (»f treatment 
in the great majority of cases is the management of c<.)nvalescence. 
'^' " patient should l>e kept in bed for at least three days, even if the 
;»erature has fallen early, and should not be allowed out, if the 
ther be cold or damp, for another week. After this, exercise in 
open air should be taken with proper j^recautions. In school 
Iren, especially those of nenrf>tic type, a rest of several weeks 
;ld l)e advised, and a fortnight after the onset a change to a bracing 
ite can usually l)e borne. In cas<'s, however, in which there has 
1 protracted l>ronrho-])n('umonia much care shoidd bo exercised 
iionths, and if the chihl fail to regain strength an<l weight in a 
-factory manner, it will be well that the cold and wet months 
M l>e sjx'nt, if j>ossil)le, in a warm and dry climate This apph'cs 
•ially to those having a tul>cn'ulMU> family history, juid to tlm-e 
whf> havcalnady |»n'-ented tuberculous manifotations (adenitis, etc.). 
' Whooping- Cough (pertussis) occurs in cpideniias, and is the 
source of a very large mortality among children. It is most preva- 



116 ACUTE SPECIFIC INFECTIOUS DISEASES 

lent and serious during the period of its first dentition, but may 
occur in infancy. It is comparatively rare after the age of ten years. 
It is extremely infectious in the prodromal stage, when the symptoms 
are not characteristic, and the infection may be carried by fomites. 
A patient becomes infectious as soon as the catarrh sets in, and before 
the characteristic wlioop develops. 

The infective agent has not been certainly identified. The mucus 
expectorated at the end of a paroxysm contains small yellowish 
lenticular masses containing a small diplococcus, which, according to 
Ritter and others, is not found under other conditions. This organ- 
ism appears to be confined to the lower part of the trachea. The 
morbid anatomy of whooping-cough is in the main that of its com- 
plications — bronchitis and broncho-pneumonia in particular. The 
only lesion at all characteristic is slight tracheitis, the reddened and 
swollen mucous membrane being covered by a very tenacious mucus. 

The incubation period varies a good deal, probably from five to 
thirteen days. It is succeeded by a catarrhal stage, during which 
the child suffers from coryza, which becomes complicated by more or 
less severe bronchitis, and often by broncho-pneumonia. The cough 
becomes worse, and by degrees paroxysmal, until at the end of a 
week or ten days the 'paroxysmal stage becomes established. When 
well developed, a paroxysm is extremely distressing to witness. The 
child's face assumes an expression of painful apprehension ; cough, 
which it tries to suppress by holding its breath, then begins ; the 
coughs succeed each other more and more rapidly, until the chest is 
in extreme expiration. The face is red or purple, the eyes suffused, 
a thin mucus runs from the mouth, and the child stands clutching a 
chair or its nurse's apron. After a short pause, during which the 
chest is motionless and no sound is uttered, a long inspiration is 
taken which is accompanied by the characteristic whoop, a long- 
drawn, high-pitched full note, to be heard for a great distance. The 
whoop may be repeated two or three times with diminishing inten- 
sity, or the first inspiration may be imperfect and the whoop slight, 
the succeeding whoop being very loud. The paroxysm may now 
end, or the cough may begin again, ending again in a whoop. Fi- 
nally, after several such attacks the paroxysm ends with the expul- 
sion of a thick, tenacious, but usually clear mucus. This is effected 
by a kind of pharyngeal regurgitation, which is not true expectora- 
tion, and may be observed in infants. Very often the regurgitation 
determines true vomiting, any food in the stomach being expelled 
along with the mucus. When the cough has existed for some time 
the muscles of the upper part of the abdomen become very tender, ' 
and every movement of them is painful. In the latter stages of the 
disease the paroxysms are often more dreaded on account of the , 
pain thus produced than for their severity. Haemorrhages from the | 



WHOOPiyO-CO UGH. 1 1 7 

mucous membranes of the nose and throat are not nneonmion dur- 
ino: the paroxysmal staov, and sul)eoniunetival eeehymoses are very 
often produced. They are app:irently due to the extreme venous 
congestion ciuised by the expiratory spasm which precedes the 
whoop. After a paroxysm, or a series of paroxysms, the cliihl is 
often left in a condition of great exlianstion, amounting sometimes 
to coHapse, which hists for half an hour or more, during which time 
it lies motionless, limp and apparently unable to move. In some 
cases loss of sensation has been associated with the ])aresis. In 
others, various forms of sensory aphasia have develojKHl and have 
persisted for several weeks. Sometimes the child is able to speak, 
answer questions, and recognizes people and objects, but is unal>le to 
find the names of objects with which it had been perfectly familiar. 
In other cases, again, the power of speech is almost completely lost, 
only a few simple words being retained, and the patient is unable to 
recognize persons and objects with which it was well acquainted 
(apraxia). In some of the cases in which nervous symptoms of 
this order occur, general convulsions take the place of the exhans- 

I tion following the paroxysms ; in others, the spasmodic movements 
are limited, as in one case recorded by Troitzky, in which there were 
facial convulsions, irregular movements of the eyes, and retraction 

; of the head. The convulsions, however, may be followed by par- 
alysis, which has nsually a hemiplegic distribution. The paralysis 
may be limited to the muscles supplied by one or more cranial 
nerves, as in the case shown in the illustration on the oj)posite page, 
in which the sixth and seventh nerves on the left side were paralyzed. 
Or it may be a regular hemiplegia affecting the face, arm, and leg 
on one side, and has been proved to be due to ha?morrhage in some 
cases, but in others recovery takes place in a few weeks, and is so 
complete that it is difficult to suppose that the symptoms can have 

I been due to actual extravasation. 

I The paroxysmal stage endures in mild cases two or three weeks 
only, but the average is perha})s five weeks. Very often, aft<'r the 

.paroxysms have diminished in number to two or three in the twenty- 
four hours they again become frequent, owing in some cases to an 
"**'K'k of coryza. After the characteristic whooping attacks have 
-o<l, the child nsually suffers for some weeks, often for months, 

, from paroxysmal cough with slight chronic l)ron('hitis. This is ])ar- 

jticularly the case in the winter and spring seasons, during which 

I cough and bronchitis are apt to persist until the weather becomes 

: lial. Many cases of chronic winter bronchitis in children date 

II an attack of whooj)ing-cough. The most important ronij/fim- 

li'fii is broncho-pneumonia (f/. v.), which is the cjiuse of the great mor- 

'tality attributable to whof>ping-cough, and is seldom absent in fatal 

; cases. Broncho-pneumonia comes on usually during the early part 



118 



ACUTE SPECIFIC INFECTIOUS DISEASES. 



of tlio paroxysmal stage, and its onset is attended by sudden rise of 
tenii)crature dyspncea, and nsnally by cessation of the paroxysmal 
cough and whoop. Tracheitis and bronchitis are present to some ex- 
tent in most, if not in all, cases of whooping-cough. The bronchitis 
is sometimes very extensive, and is then a serious menace to life, not 
directly so much as by the extra strain it puts upon the heart already 

Fig. 8. 




Paralysis of the Sixth and Seventh Cranial nerves coming on during Whooping-Cough, and due 
probably to limited hiemorrhage into the Pons (Dr. Craig's case, Brit. Med. Journ., 1896, vol. i., p- 
1440). 

strained by the congestion of the right side produced by the parox- 
ysms. In such cases the dyspncea may be extreme, the face livid or 
purple and swollen. In slight cases there is pallor and cedema of 
the low^er eyelids. 

The diagnosis of a well-marked case of whooping-cough during the 
paroxysmal stage is easy, since the paroxysm of coughing .ending in 
the high-pitched whoop is characteristic. The only condition which 



ii 



WHOOPiyG-CO VGH. 1 19 

resembles it nearly is that paroxysmal cough and inspiratory stridor 
produced by enh\rgoment of the trachco-bronchial ghinds (<y. r.). Dur- 
ing the catarrhal stage, however, diagnosis may be impossible, unless 
the child is known to have been exposed to inftvtion. If there be 
much broncho-pneumonia the paroxysms and whooping usuallv do 
not appear, or are suspended until it begins to resi>lve. Tiic exist- 
ence of ulceration of the fnenum lingua^ may increase a suspicion al- 
ready existing, but is not in itself characteristic, esjK'cially in young 
children who have recently cut the lower incisors. The mistakes 
most liable to be made are to overlook whooping-cough in the early 
stage, or to attribute the paroxysmal cough of enlarged glands to a 
raihl attaek «»f Avho<»ping-cough. 

The treatment is unsiitisfactory because no remedy has much effect 
on the duration of the malady, and because it is inijxjssible to fore- 
see which one of the numerous drugs at nur disposal will have the 
best effect. The main indications which we can hope to lulfill are to 
diminish the number and severity of the attacks and to prevent com- 
plications. Exjx'ctorants are valuable in the early stage, especially 
ipecacuanha with which antipyrin may usually be combined with ad- 
vantage ; the dose of the latter drug should be at first a grain for 
each year of life three times a day. Belladonna, which is much used, 
is often very effectual in lessening the severity of the paroxysms. 
It is the l^est drug for infants and young children, but must be 
given in sufficient doses (ext. gr. J, tinct. Ill iij-ij) to an infant three 
four times a day. The production of dryness of the throat should 
avoided, but sliglit flushing of the face should follow each dose 
icobi). Bromoform in some cases diminishes the severity of the 
paroxysms after a few days, l>ut it is not suitable for young children, 
and is uncertain in its action, as is also cocaine, which has Ix'cn 
recommended in doses of gr. -^^ for an infant, gr. J for a child of 
^'}\ years, thrice a day. [Bromoform may be given m- follows : 

Broniof(»rm, v\\'] 

rn. Aniytr., tt\^x 

Trucil TraL^c;im.. TT\^xv 

Aq. Cam., ad 5J 

Appendix.] 

in r»lder children good results are sometimes obtained l)y giving fjuininc 
(sulphate or hydrochlorate gr. iij t. d.) or the tannate, which is less 
bitter, in ])owder (gr. vj-x t. d.). Oxymel of squills, 3iij-iv, in 
'^'vide<l doses during the aftenuKm for a child of five has lxH?n recfmi- 
nde*l, and the drug in some cases has a iK-neficial action. When 
there is o-ilema of the face, and weakness of the heart, it is well to 
give small doses of digitalis, and to increase them gradually if neces- 
sary. When sleep is much disturl>e<] by the paroxysms two or 



120 ACUTE SPECIFIC INFECTIOUS DISEASES. 

three doses of potassium bromide taken during the afternoon and 
evening often procure a quiet night. 

Local treatment directed to the upper air passages is not to be 
neglected. The nose should be kept clean, and a small quantity of 
borac acid ointment (to which menthol, gr. xx to 5j may be added) 
should be introduced into the nose two or three times a day. Nasal 
insufflations have also been strongly recommended ; for this purpose 
powdered benzoin and lycopodium equal parts, or bismuth salicylate 
five parts, benzoin five parts, quinine sulphate one part, may be used. 
Local applications of antiseptic solutions to the pharynx and upper 
orifice of the larynx undoubtedly do good ; indeed I have seen more 
striking results from the application of a solution of recorcin (2 per 
cent.), as recommended by Moncorvo, than from any other method 
of treatment, but like all other remedies, it fails more often than it 
succeeds. The diffusion of terebinthinate vapors through the room, 
as by the old fashioned method of stirring Stockholm tar with a hot 
poker, gives relief, and advantage is to be derived from diffusing 
turpentine through the air by evaporation.^ 

" Hygienic treatment '^ is of the first importance. The child's 
bedroom should be well ventilated by night, and thoroughly aired by 
day. It should spend as much time as possible out of doors every 
day, and as soon as convalescence is established change of air is to 
be recommended, by preference to a dry elevated site. 

The diet through the height of the attack should be light and 
nourishing. When vomiting is very troublesome sedatives may become 
necessary — morphine, codeine, or cocaine — but their use may often 
be avoided by giving liquid food only, either iced, or as hot as can 
be taken, and choosing the period shortly after a paroxysm for its 
ingestion, the child being made to lie down for a short time. Most 
important is the prophylaxis of broncho-pneumonia. The risk of 
this complication, possibly also the severity of the disease itself, is 
increased when many children are treated together in the same room 
or w^ard, and under such circumstances the most rigid precautions 
should be observed as indicated in the chapter on broncho-pneu- 
monia. 

[Pertussis, like measles, acts as a predisposing cause of tubercu- 
losis by diminishing the general resisting power of the patient and 
thus rendering the mucous membrane of the respiratory tract sus- 
ceptible to invasion by the bacillus of tuberculosis. Hence it is im- 
portant to watch carefully debilitated children, and those with a 
tuberculous heredity for several months after apparent convalescence 
and to secure for them the best hygienic and dietary conditions pos- 

' It has been recommended to burn sulphur in the bedroom about five hours before 
bedtime and to keep the room closed until just before the child is put to bed. UU- 
mann burns sulphur thrice a day for a quarter of an hour in the room in which the 
child is. 



M^^fps. 121 

sible. The practice commonly in vogue of allowlno: ])atients with 
pertussis to return to an «nit-patient clinic is criminal and cannot he 
too severely condemned.] 

Mumps [Epiilemic Parotitis) is an acute infectious disease charac- 
terized by intlammation of the salivary glands, usually the ])arotid. 

The disease affects children (five to fifteen years) mainly, and l)oth 
extremes of life are almost immune. It is disseminated mainlv l)v 
personal communication, and is extremely infectious, especially in the 
early stage. The infectiousness of a patient diminishes progressivelv 
from the time of onset of the parotitis, and has ceased in at most 
three weeks from that time. 

The iiicnbation period, /. r., the interval between exposure to in- 
fection and the onset of parotitis, is usually three weeks, but mav be 
a few days longer, or as much as a week shorter. 

The prodromal period lasts three or four days, during which the 
patient is capable of transmitting the infection, but the symptoms 
are slight and not characteristic — malaise, headache, loss of a])petite, 
and sometimes elevation of temperature. AVith the onset of }>arotitis 
the temperature rises to 101-103° F., and complaint is made of pain 
behind the jaw, and difficulty in opening the mouth. Swelling in 
the parotid region is noticed a little later, usually at first on one side 
only. In the course of thirty-six to forty-eight hours it becomes 
very considerable, and has generally begun on the opposite side also. 
It extends in front of the ear and under the sternomastoid muscle, 
producing a characteristic deformity. The skin is tense and full, but 
is not, as a rule, reddened ; not infrequently there is extensive 
oedema of the face and neck. During the enlargement of the gland 
it is tender and the pain in it may be acute ; even if slight it is 
elicited by any movement of the jaws ; for this reason and on account 
of the mechanical obstruction, and sometimes of spasm of the massc- 
ters, there is difficulty in feeding, and the patient s})eaks " thnuigh 
his teeth.'* Pharyngitis is present in many cases, and is sometimes 
accompanied by tonsillitis, but, owing to the difficulty of opening 
the mouth, its existence can only be surmised in most well-marked 
cases. Stomatitis is an occasional complication. Tlie paroti<l swell- 
ing begins to subside on the sixth or seventh day, but before this the 
fever has usually disapiK'ared, and convalescence is rapid in uncom- 
plicated cases. Occasionally the lymj^hatic glands behind the angle 
of the jaw are found to be enlarged after the parotid has subsided, 
and so remain for some weeks. Mumps is usually a mild disease, 
but sometimes the fever is ver\' high and is accompanic<l by delirium 
and prostration. In such cases meningitis has been found, and in 
most of the com|)aratively few fatal cases on reeord has bem the 
cause of death. The delirium is occasionally mania«d,and has bem 
followed by insanity. The other salivary glands, the submaxillary 



122 ACUTE SPECIFIC INFECTIOUS DISEASES. 

nion^ rarely the sublingual, are sometimes involved, very rarely the 
hic'lirynial ij^land, still less often the thyroid. The testicles and ovaries 
are in some cases the seat of an inflammatory affection analogous 
to that which affects the parotid. Orchitis may precede or accom- 
pany the parotitis, and has been known to occur alone (orchitis paro- 
tidea). It is very rare in young children, but becomes more frequent 
after thirteen. The onset of this complication is marked by a rise 
of temperature, severe pain in the testicle and groin, accompanied 
often by delirium. It is sometimes attended by purulent discharge 
from the urethra, and may be followed by atrophy of the testicle. 
As a rule one side only is attacked. Orchitis occurs in about one- 
fourth of the cases, and atrophy in about half the cases of orchitis. 
Ovaritis is much less common. Mastitis may occur in either sex. 
Vulvo-vaginitis may accompany the ovaritis or occur independently. 
Suppuration of the parotid is very rare, but even gangrene has oc- 
curred. Mumps is often attended by pain in the ear, and by deaf- 
ness which passes away usually as the swelling of the parotid sub- 
sides, but may persist longer, and even be permanent. Laryngitis 
is a rare complication, but has caused death by oedema glottidis ; 
broncho-pneumonia occasionally develops with great rapidity. Albu- 
minuria is present during the height of the fever in about 30 per 
cent, of the cases, and marked nephritis with oedema after the fever 
has subsided has been recorded. Relapses are rare. 

The pathology of mumps is not well understood. Laveran and 
C^atrin found in the blood, and in the affected parotids and testicles 
a micrococcus — usually in pairs — which could be cultivated at 35° 
C, but inoculations in animals were negative. The analogy which 
epidemic parotitis presents to the parotitis which occurs as a compli- 
cation of intraabdominal suppuration, has led to the view that the 
inflammation arises in the ducts, but such anatomical evidence as ex- 
ists points to the interstitial tissue as the part affected. When the 
testicle atrophies after orchitis the whole organ becomes soft, the 
seminiferous tubules lose their epithelium, and there is an over- 
growth of connective tissue. 

The diagnosis is usually easy, as parotitis from other causes is very 
rare in childhood. Enlargement of the lymphatic glands behind the 
angle of the jaw (secondary usually to tonsillitis or prolonged stoma- 
titis) is often spoken of by parents as mumps, but observation of the 
situation of the swelling behind and in front of the ear, which is dis- 
placed outwards so that the lower part of the auricle stands out, 
ought to prevent the possibility of a mistake. The chief risk of 
error is that the disease may be overlooked if the parotid swelling is 
slight, and an epidemic thus permitted to start in a school. Pro- 
phylaxis is rendered difficult by the early commencement of infec- 
tion. If the patient be isolated in a room apart from other children, 



GLANDULAR FEVER. 123 

the infection will nut as a rule sjn'ead beyond those already inirctcd. 
Infection may have taken ]daee in any children who have heen in 
contact with the patient during the four days previous to the paro- 
titis. A child who has been exposed to infection should not hv 
allowed to mix with other susceptible children, as, for instance, in a 
school, until twenty-five days after its exposure ceased. 

Treatment cannot arrest the course of the disease. AVhile the 
temperature is raised the patient should be kept in bed, and at the 
onset he should take a purge. Hot applications to the swollen part 
are grateful to the patient at first, and later a cotton-wool pad should 
be applied. The m()Uth and j>harynx should l)e kept clean by the 
use of gargles, h)tions, and sprays. Very acute swelling and pain 
should be treated by belladonna fomentations or belladonna and gly- 
cerine smeared on the part and covered with cotton-wool. High 
temjxrature and delirium call for s]>onging with cool water and the 
ice (^p, while (piinine and anti])yrine may be given together or sep- 
arately. The food should be light, and at first fluid only. The 
tendency to constipation is often troublesome, and should be met by 
the exhibition every morning or every other morning of a simple 
laxative, -iieli a- liquorice j)owder. 

Glandular fever was described by Pfeiffer in ISSII' as a fever 
attended by adenitis and due to specific infection. 

The disease has been seen in infants as young as seven months, 
and in children of thirteen years, but the majority if the cases occur 

rween the ages of four and seven years. 

The infection, of which the agent has not been isolated, is little 
diffusible, but most of the children in a family suffer. J. P. West 
has descril)ed recently- an ej^idemic which spread very slowly 
through a thinly inhabited district of Ohio. The period of incuba- 
tion is probal)ly about seven days. 

The child is taken ill suddenly with headache, pain and stiffness 
in the neck, some pain on swallowing, and often general pains in 
the back and limbs, which may suggest the onset of rheumatism. 
At the same time the tem}>erature rises to about 102° F., the j)ulse 
becomes rapid, and respiration is cpiickened. The face is flushed, 
but there is no rash. On the secc>nd or third day a swelling is 
noticed behind the angle of the jaw, and extending along and be- 
neath the sternrjmastrud muscle. On palpation it is found to con- 
sist of three or four glands, which are enlarged, firm and tender. 
In about two days this adenitis, which begins usually on the left side, 
reaches its height, and the corresponding glands on the other side 
then l>egin to enlarge. Other cervical and the axillary and inguinal 
glands may be affected. Pain in the aUlomen is often present, and 

^ Jahrb. f. KinderfUtlr., IJand xxix., s, 2.'j9. 
^Arrh. of PedifUriri, Dec, \WM\. 



124 ACUTE SPECIFIC INFECTIOUS DISEASES. 



in a considerable proportion of cases the mesenteric glands are en 
larged. The child is thirsty, but has no appetite ; the tongue has 
white coating, and there is constipation in all but the mildest cases. 
The spleen and liver are usually enlarged. There may be a little 
redness of the pharynx and tonsils, but the latter are not enlarged 
as a rule. In a small number of cases there is severe pharyngitis. 
The temperature reaches its highest point (104° F., or higher) at 
the time the swelling on the side first affected is at its height. It 
may then fall considerably, to rise again as other groups of glands 
are involved. The final defervescence occurs from a week to a fort- 
night after the onset ; it may be rapid and accompanied by the pas- 
sage of green mucoid stools. The glands suppurate very rarely, if 
ever, but remain enlarged for some days or weeks after defervescence. 
Convalescence is often slow, owing to anaemia and general depression. 
Complications are rare, but acute nephritis may occur. 

The prognosis is good, and very few deaths have been recorded. 

The diagnosis must usually be difficult, as doubts as to the specificity 
of the adenitis may well be entertained. A similar train of symptoms 
may attend adenitis secondary to obvious lesions of the mucous mem- 
branes or skin. Neumann believes that the active agents are strep- 
tococci or staphylococci which have passed through the tonsils and 
pharyngeal mucous membrane without producing local lesions ; but 
against this view is the rarity of suppuration. It has been suggested 
that the infection finds entrance through the gastro-intestinal mucous 
membrane, and that the glands on the left side of the neck are af- 
fected first, owing to their contiguity to the thoracic duct. In two 
epidemics of adenitis of the subauricular and submaxillary lymphatic 
glands the disease was shown to be, in reality, mumps, by the oc- 
currence of parotid swelling in some cases ; and this possibility 
should be borne in mind. It is said also that rubella may occur in 
epidemics, in which there is no rash, though the glandular swelling 
is well marked. 

The treatment should consist in keeping the child in bed on a fluid 
diet. The pain and stiffness in the neck may be relieved by bella- 
donna liniment, belladonna and glycerine, or by cold compresses. 
Constipation should be treated by mild laxatives or by enemata, and 
afterwards salol, naphthalin, or small doses of calomel should be 
given. Purgation does not cut short the attack, and tends to in- 
crease the subsequent depression. 

Cerebro-spinal meningitis is an acute infective disease which oc- 
curs sporadically and in epidemics. 

Numerous epidemics have occurred in Germany and in North 
America, very few in Great Britain, where, however, sporadic cases 
are not uncommon. In some epidemics children have been attacked 
in much greater numbers than adults ; in others the reverse has been 



I 



CEREBRO-SPIXAL MEyiXGITIS. 125 

the case ; while in others, again, all ages have suffered to about an 
equal extent. Epidemics a}>pear to (.IcjkmuI upon local conditions, 
the nature of which has not been ascertained. Direct inlcction has 
not been proved to occur. 

The pathology of the disease is obscure, and the infective agent has 
not been identitied. [The (liplococcus infraccllu/dris moiinf/ifrdi.^ de- 
scribed by Weichselbaum,^ Jager,- Councilman,' Mallorv,* Went- 
worth,^ and othei*s, is at the present writing universally conceded 
to be the cause of epidemic cerebro-spinal meningitis. 

It is a diplowccus found inside the pus-cells in tlie meningeal ex- 
udate, in the spinal fluid obtained by lumbar puncture, in the nasal 
secretions and in the purulent discharge of an otitis occurring as a 
complication.] There is a general meningitis affecting the membranes 
both of the cord and of the brain, with extreme congestion of the 
brain and cord, accompanied sometimes by actual ha?morrhage or 
disseminated areas of encephalitis. On the surface of the cerebral 
and spinal membranes purulent exudations may form, and there is 
some effusion into the ventricles. In more chronic cases the menin- 
gitis is plastic, characterized by adhesion and thickening, and the ef- 
fusion into the cerebral ventricles may be consideral)l('. Pneumonia, 
pleurisy, endocarditis, and nephritis may occur as complications. In 
severe cases extensive haemorrhages into the skin and serous mem- 
branes may occur early, and the patient may die before the menin- 
geal lesions have become well marked. 

The symptoms usually come on suddenly, or there may i)e for some 
days headache, backache, and malaise. The earliest symptoms are 
headache, shivering, rigor or convulsions, and rise of temperature to 
101° or 102^ F. The headache increases, the neck becomes stiff 
and painful, there is photophol)ia and dread of noise, and great rest- 
lessness and irrital)ility. The stiffness of the muscles of the neck 
passes on into extreme rigidity, so that the body is stiff like a statue, 
or there may be extreme retraction of the head. Pain in the back 
and liml)s is present, and may be very severe, and there may be 
spasm, clonic or tonic, of the liml)s and of the face. Stral)ismus is 
tVequent symptom. In addition to the pain in the back and occi- 
pital region, there may be hypenesthesia along the spine. At the 
onset there may l)e convulsions or furious delirium, which, as the 
effusion increases, gives place to somnolence, and finally to eoma. 
The pulse is usually very rapid, but the respirations are not much 
hurried, and may he slow or present the C'heyne-Stokes character. 
The temjx'rature may not rise much after the first elevation at the 

' Weichselljaura : Foiiswhrillf der Medirine^ JUl. 5, 1H87. 
'Jaetrt-r: /yiturhrift f. Hufjirrw n. Injfrtionxkrnnk., W\. 19, 1895. 
'Councilman: Trnnjf. A^jtrtc. Amrr. Phynir.^ 1897. 

* Mallftry : Patliologioal Te<hnique. 

* Wentworth : Boaton Mai. and Surg. JournfU, Vol. ('XXX VIII., No. 11. 



12() ACUTE SPECIFIC INFECTIOUS DISEASES 

onset, or it may fluctuate very much, or it may show a steady rise, 
reac'liino" 10l3° to 108° F. before death. Herpes is extremely fre- 
quent, and rose-colored spots like those of typhoid, urticaria, erythema 
nodosum, and ecthymatous and pemphigoid eruptions are among the 
various rashes which have been observed ; but the most common skin 
lesion is hnemorrhage into the skin. Sometimes petechise and purple 
sp ;)ts are very numerous and cover almost all parts of the skin. The 
bowels are usually constipated, but there may be diarrhoea. Vomit- 
ing, which usually occurs at the onset, is not a prominent symptom 
subsequently. The urine may contain albumen, and in the most 
acute cases blood. Death may occur in so short a time as twenty 
hours, before the development of characteristic symptoms, or the case 
may run a subacute course lasting many weeks, or even months, and 
eventually end in recovery. Usually, however, if recovery is to take 
place, improvement begins between the fourth and sixth day. Pneu- 
monia is the most important complication, and blindness from optic 
nerve atrophy, and deafness from labyrinthine disease the most seri- 
ous sequelae. 

The prognosis is uncertain. In severe cases, with petechise and ex- 
tensive rigidity, it is bad. Herpes is also an unfavorable sign. The 
death-rate varies very much in different epidemics. It may be as 
low as 2 or 3 per cent., or as high as 75 per cent. The disease is 
generally more severe in children than in adults. The diagnosis may 
be impossible in sporadic cases, since the symptoms closely resemble 
those of tuberculous meningitis. Well-marked rigidity, the occur- 
rence of herpes, a regular pulse, and the absence of the peculiar soft 
feeling of the abdomen usual in tuberculous meningitis, may point to 
the true diagnosis. When both pneumonia and cerebro-spinal men- 
ingitis are present, it may be impossible in sporadic cases to deter- 
mine which is the primary disease. Cerebro-spinal meningitis pre- 
sents often a great resemblance to typhoid fever with pronounced 
cerebral symptoms ; and if the symptoms of the former are not well 
marked, diagnosis may ])e quite impossible, since enlargement of the 
spleen may or may not l)e present in both. 

[Most authorities ^ concede that a positive diagnosis can be made 
by means of lumbar puncture. It consists in tapping the spinal 
canal in the lumbar region and examining the fluid macroscopically, 
microscopically, and bacteriologically. Thus we can always detect 
the presence of a meningitis by a greater or less degree of turbidity 
of the fluid, normal spinal fluid being clear. Also we can often by 
further examination of the fluid and its sediment, by cultures and 
inoculation experiments, determine the kind of meningitis present, 
cerebro-spinal, tubercular, etc. In the cerebro-spinal variety, the 

'For technique, see Wentworth, Trans. Amer. Pediatric Soc, Vol. VIII., 1896, 
and Wentworth, loc. ciL; also jiage 5.34, below. 



i 



TYPHOID FEVER. 1J7 

fluid obtained is more or less turbid, and contains some se<liment, 
cover-glass preparations of which show " numerous polvmorj^ho- 
nuclear leucocytes," " pus-corpuscles," occasional smaller mononuclear 
lymphoid cells and fibrin. Groups of the diplococcus intracellularis 
are found in varying numbers in the protoplasm of some of the leuco- 
cytes.] 

The treatment must be symptomatic. The severe headache and 
stiffness in the neck may be relieved by dry cupping, and by tiie 
application of ice-bags to the head. Of internal remedies for the 
spasm, morphia, either by the mouth or hypodermically, is thc^ most 
etticacious, but bromides are also useful. Potassium iodide has been 
thought to exercise a beneficial effect on the meningitis. The patient 
should be carefully fed, if necessary by the stomach tube. 

Typhoid fever {enteric fever) is an acute specific disease due to 
infection by the bacillus typhosus, an organism which resembles 
closely the b. coli communis. 

The bacillus is localized mainly in the lymphoid tissue of the small 
intestine, esi)ecially in Peyer's patches, where it produces a specific 
inflammation ; but it may l>ecome established secondarily in other 
organs. The intestinal inflammation may terminate in sloughing 
and ulceration, or in resolution, which occurs more often in children 
than in adults. The infection is disseminated usually by water, 
sometimes by milk or cream which has become contaminated by 
water specifically ])olluted, more rarely by contaminated utensils or 
, uncooked vegetables. 

Typhoid fever is a milder disease in children than in adults, its 

, course shorter, its symptoms less severe, its mortality lower. 'J'he 

severity increases directly with age, ' and is greater at ages over than 

under ten years. It is as common between five and ten as between 

, ten and fifteen. It is probably very rare in infants, and is seldom 

j recognized under two years of age, a period of life when the symp- 

j toms are extremely mild. The proportion of children infected during 

an epidemic varies, but is often high when the infection has l)een 

<li-tributed by milk. 

fhe incitfxtfion period varies within rather wide limits. It is most 
oiten twelve to fourteen days, not infrequently nine or ten, occasion- 
' ally less. It probably never much exceeds three weeks. Infection 
■ may l)e derived from a patient during the whole course of the fever, 
I and for the first fortnight of convalescence. It uimv be rcfaiiuil bv 
I fomites for two months at least. 

j The ]n/rr.ri/f of tv|»hoid fever may be divided into iw<» periods; 

, (1) The periml of primary or siMcific fever, corresponding to the 

invasion and establishment of the disease, during which the s]>ecific 

^ inflammation of the lymphoid structures of the intestines takes place ; 

'J. L. Mor^-. //.W. Mr,I. and Snrq. Jonrn., Feb. 27, 1896. 



128 ACUTE SPECIFIC INFECTIOUS DISEASES 

and (2) the period of secondary or suppurative fever attending the 
formation and separation of the intestinal sloughs and the consequent 
ulceration. 

The omet is more often acute in children than in adults, and in 
children under ten than in those over ; yet in from half to two-thirds 
of the cases in children the onset is insidious. The earliest symptoms 
may be shivering or a rigor, more often vomiting. The temperature 
rises at night and falls in the morning, the morning fall being less 
and the evening rise greater for five or six days, until the maximum 
is reached. The temperature continues to show fairly regular oscil- 
lations, morning fall and evening rise, for about a week. With the 
development of the secondary period the oscillations gradually grow 
wider, the remissions being more marked and the evening maxima 
somewhat less high ; the range of the diurnal oscillation becomes 
gradually less, until finally, after a variable period, three to five 
weeks after the onset, the normal is reached. When the onset is 
sudden, the maximum may be reached within the first two or three 
days. During the period of primary fever the oscillations are often 
much greater than in adults. Owing to the frequency with which 
resolution of the intestinal inflammation occurs without suppuration, 
secondary fever is in children absent in many, probably about half, 
the cases. The average duration of the fever is less than three 
weeks, and in children under ten is often much shorter — less than 
two Aveeks. The pulse is soft and increased in rapidity, but not in 
proportion to the height of the temperature. A systolic apex mur- 
mur is heard in many cases, but disappears during convalescence, 
and marked cardiac weakness may occur during the fever or during 
convalescence. 

The symptoms are commonly not well marked in children, and the 
younger the child the less characteristic are they. Diarrhoea is ab- 
sent in a large number, probably the majority, of cases, and consti- 
pation may be a troublesome symptom. Morse records diarrhoea in 
32.5 per cent, from five to ten years, and in 42 per cent, from ten 
to fifteen years ; but it was severe in only 2.6 per cent, at the earlier, 
and 2 per cent, at the later age. Tympanitic distension of the 
abdomen is common, but tenderness is often very little marked, 
especially in children under ten. Enlargement of the spleen is the 
rule ; it is often slight, l)ut in young children may be very consider- 
able, especially in the early stage. The tongue is tremulous ; it may 
be clean, but it is usually thickly coated with a cream-colored fur. 
Dryness of the mouth and tongue, and cracked lips, are far less 
common than in adults. Hremorrhage from the intestines is com- 
paratively infrequent and perforation extremely rare. 

A roseolous eruption occurs as in adults in most cases ; but it is 
usually scanty, and often disappears rapidly. Other eruptions are 



TVrnOID FEVER. ^'2\) 

rare, but suclaniina, maoiilie, petechia^ and ocohymosos, urticaria, and 
labial herpes may occur. Boils, sometimes in large numbers, mav 
ciuise much discomfort during the later stage of the attack and in 
convalescence. Bronchitis is a less frequent, but, when present, a 
more prominent symptom than in adults. Some broncliial catarrh 
occurs in from a third to half the cases, but severe bronchitis is most 
c^Miimon in young children. Broncho-pneunu>nia and pleuro-pneu- 
monia are not uncommon. Acute pharyngitis may produce marked 
symptoms at the onset, and laryngitis occurs in a considerable pro- 
j>ortion of cases in some epidemics. The fiice is dusky, and wears 
an expression of depression and lassitude. The patient lies on his 
back in bed, and appears to wish only to be left alone. The severitv 
of the nervous symptoms varies greatly ; not infrequently they arc 
very slight, though headache, not usually severe, is present in the 
majority of cases. It disappears with the onset of delirium, which 
is usually mild and wandering, but sometimes noisy at night. In a 
small number of cases — the proportion being larger under ten years 
— there are marked nervous symptoms, suggesting meningitis — re- 
traction of the head, opisthotonos, pain and tenderness in the neck, 
photophobia, inequality of the pupils. Suppurative otitis media is 
a not infreipient complication, and may be attended l)y meningeal 
symptoms, pain causing fits of screaming, delirium, and high tempera- 
ture. Epis.taxis is common, but is seldom severe. Albuminuria is 
frequent, but true nephritis is said to be rare. [A changed mental 
condition sometimes occurs during convalescence. Thus some chil- 
dren show a marked irritability or moodiness, others again are ex- 
tremely forgetful, have less power of concentration and are easily 
fatigued by any mental exertion. Such children should be care- 
fully watched as t<> their school-hygiene and no excess in studies 
allowed.] 

The diagnosis may be very difficult, owing to the absence of char- 
acteristic symptoms. If in the early stage bronchitis or pneumonia 
be present, all the symptoms are very apt to be attributed to these 
complications. Even after death, bacteriological examination ah»ne 
may suffice to determine whether the swelling of Peyer's patches 
and the mesenteric glands is specific. At a later stage the continuous 
fever, coated tongue, dusky face, and abdominal tenderness may 
enable a diagnosis to be made even in the absence of characteristic 
diarrha-a. When nervous symptoms are prominent, the resemljlance 
to tulxjrculous meningitis may be close, and acute general tuberculosis 
may be mistaken for typhoid fever (see " Tul)erculosis," p. 108). 
Such cases have lx?en mistaken also for epidemic cerel)ro-s])inal men- 
ingitis, the error l>eing discovere<l only jtost-mfn-tnii. In malarial 
regions the autumnal tyjie may present a striking similarity in it.s 
early days to typhoid fever, and the diagnosis may be {wssible only 
9 



130 ACUTE SPECIFIC INFECTIOUS DISEASES. 

l)v the discovery of the malarial parasite in the blood (Osier). In 
fiitnre the serum method of diagnosis will probably be of great use 
in those cases in which it is available. 

[Recent research has conclusively demonstrated the Widal serum 
test to be of practical value in many cases. The reaction when found 
is proof positive of the presence of typhoid : a negative result is of 
little diagnostic significance. The reaction is found as early as the 
seventh day, disappearing a varying length of time after the cessa- 
tion of the disease.] 

The prognosis, as already indicated, is more favorable in children 
than in adults. Extreme tympanites, especially if accompanied by 
vomiting, is a bad omen, as is also the early onset of nervous symp- 
toms or great depression. Bleeding from the bowel, if small in 
quantity, is not necessarily serious, but if repeated frequently, or very 
•copious, indicates serious ulceration and imperfect repair. 

In treatment the main indication is rest in bed. Good nursing is 
essential, and special care should be taken to keep the patient clean 
and free from bed-sores. Milk should form the main part of the 
food, but it should be given diluted, and the effect on the comfort of 
the patient and the condition of the stools watched, since the thirst 
from Avhich the patient suffers may easily induce him to take more 
milk than can be digested. A mineral water containing a low pro- 
portion of carbonic acid is a good beverage, or water acidulated with 
hydrochloric acid, citric acid, or lemon juice. When constipation 
exists vegetable soups may be tried, or a small dose of castor oil may 
be given. 

The cold bath treatment has not yielded satisfactory results as a 
routine measure, and the use of warm baths cooled down by the ad- 
dition of ice or cold Avater is only called for in cases in which the 
temperature remains elevated for an unusual time. On the whole, 
the best results have been obtained by the most simple means. 
When diarrhoea is severe, which is not often the case, it may usually 
be checked by an enema of starch and opium. As a rule, it will be 
found to be due to the presence of curds or other irritating remnants 
of food, and to moderate as soon as the diet is regulated. Haemor- 
rhage from the bowel will be treated on the same principles by di- 
minishing the amount of food, by allowing the patient to suck ice, 
and only in severe cases by the administration of acetate of lead and 
opium. Tympanites may be relieved by the application of turpen- 
tine stupes. In the management of convalescence the safest rule is 
to permit no solid food until ten days after the temperature has be- 
come normal, and to keep the patient in bed for this period. 

[Great care should be taken in the disinfection of all excreta. If 
the discharges be in a vessel, they should be covered with a solution 
of carbolic acid 1 : 20 for a period of six or eight hours before being 



II 



TYPHOID FEVER. 131 

thrown away. All napkins should be similarly treated and then 
boiled, or if possible burned. The bed linen shouUl be boiled sepa- 
rately from the family wash. 

The investigations of Kiehardson (Boston) in the urine of typhoid 
adults are of great praetieal importanee. He has demonstrated the 
presence of typhoid baeilli in the urine of convalescents for weeks 
and even months after the acute stage, and states that their elimina- 
tion is hastened by the administration of urotro})in. He advises giv- 
ing this drug, 30 grains daily, for 10 days, beginning with the third 
or fourth week of the disease.] 



CHAPTER VIII. 
ACUTE SPECIFIC INFECTIOUS DISEASES {concluded). 

Diphtheria — Incubation Period — Pathology — Symptoms — Diphtherial Palsy — Diag- 
nosis — Prognosis — Antitoxin Treatment — General and Local Treatment — [Im- 
munization]. 

Diphtheria is a specific inflammation affecting the mucous and 
cutaneous surfaces, produced by a specific bacillus, and characterized 
by the formation of membranes. 

The interval between exposure to infection and the development 
of characteristic symptoms is variable ; it is most often two days, 
and does not as a rule exceed four days. Infection may be derived 
from a patient suffering from diphtheria in the incubative stage, 
during the attack, for a period of long and probably varying dura- 
tion after apparent recovery, from fomites, or from contaminated 
milk. It may be derived from mild or anomalous unrecognized 
cases. 

The diphtheria bacillus, called after its discoverers the Klebs- 
Loffler bacillus, grows readily on blood-serum containing glucose 
and bouillon, but also on other culture media. It flourishes best at 
98° to 101° F., forming elevated grayish-white colonies with opaque 
centres, Avhich first become perceptible about fifteen hours after in- 
oculation of the tube. The bacillus itself, w^hich is not motile, and 
is not known to form spores, is 2.5 to 3 /j. long, and about one-fifth 
of this in breadth ; it is slightly thickened at each end and curved. 
It varies very much in virulence, some specimens being harmless. 
The less virulent bacilli (pseudo-diphtheria bacilli) are usually shorter 
and straighter, and grow more freely at low temperatures (68° F. or 
less). The bacillus is very resistant to drying, and its virulence when 
attenuated, but not suppressed, may become restored. In a state of 
little or even of considerable virulence the bacillus may be present 
in the throat or nose without producing any lesion, and it is probable 
that it can only attack the epithelium when this has been damaged. 
The presence of the streptococcuo pyogenes in association with the 
diphtheria bacillus appears to exalt the virulence of the latter. The 
streptococcus also by attacking the epithelium may produce a lesion 
which will enable the diphtheria bacillus to establish itself. This 

132 



DIPHTHERIA, 133 

may account for some of those cases of, often, very virulent diph- 
theria Avhicli arise without any discoverable source of infection, aftcM* 
exposure to ci^ld or as a complication of scarlet fever, measles, tvphoid 
fever, and other acute diseases. 

The bacilli, once enabled to attack the mucous membrane or skin, 
kill the epithelial cells, and excite inflammation witli ellV.sion of 
fibrin and migration of leucocytes, wliich are likewisi> kiUed in greater 
or less number ; after a time a patch of false membrane is thus pro- 
duced. At the i>eriphery of the membrane the epithelium is prolifer- 
atincr, and infiltrated with white and red corpuscles and fil)rin. At 
the focus the epithelium is replaced by false membrane, wliich con- 
sists of a fibrinous exudation, in the meshes of which are contained, 
at the surface, great numbers of micro-organisms, usually, in addi- 
tion to the diphtheria bacillus, streptococci and staphylococci, be- 
neath this, fibrin and degenerating cells with a few microbes, and, 
deeper, epithelial cells, and many leucocytes enclosed in irregular 

leshes of fibrin. The bacillus may be conveyed from the original 
point of infection to other parts (1) by contact, as when one tonsil 
becomes infected from a false membrane on the other ; it may spread 

2) along passages — the bronchi, Eustachian canal, the oesophagus, or 

Mto the nose — with or without the formation of visible false mem- 
l»mne; (3) along the lymphatics to the glands; and (4) at the ap- 
proach of death, and possibly under other conditions it may be 
found in the spleen, liver, and kidneys, to which it must have been 
carried by the blood. Diphtheria, especially when it involves the 
larynx, is very frequently complicated l)y l)roncho-pneumonia (or 
l»ronchitis with collapse). In such cases, the bacillus diphtherire is 
present in the lungs ; it is associated with other microbes, but it is 
pro])able that it can itself produce broncho-pneumonia. The general 
-ymptoms of diphtheria are due to the absorption of soluble bodies,* 
which have a poisonous action on the leucocytes, and on the cellular 
elements of the organs {e. g., the kidneys, producing glomerulo- 
nephritis), but has apparently a selective action on the nervous 
system. At the same time it causes a fall of blood-[)ressure and dila- 
tation of the vessels, especially those of the lungs, liver, and kidneys, 
and diminishes the force of the heart. The blood contains an excess 
of leucocytes, is altered in color, and does not coagulate firmly. Tiic 
severity of the toxic symptoms is not in direct j)ro|K)rtion to the extent 
of the fiilse membrane, but is dependent in part on the idiosyncrasy 
of the individual, in part on the nature of the bacilliLs, some tvjM's 
apparently producing more toxin than others — and in ])art on the 
extent to which the lungs are involve<l. The fact that in severe 

ises the lungs so often contain the bacillus di|)htheriae is, it will be 

'Rouxand YerHin, Anmdrsde C Insttltut Pustenr ; Sidney Martin, Brit. }fr/l. Journ.f 
^■•2, vol. i., p. 641 et seq. 



134 ACUTE SPECIFIC INFECTIOUS DISEASES. 

seen, of importance in this connection, since it would seem that the 
quantity of toxin produced may thus be very greatly increased.^ 

True diphtherial inflammation may be complicated by the presence 
of various pyococcal organisms. Inflammation of the fauces, due to 
the streptococcus pyogenes, may become infected by diphtheria — an 
event of not infrequent occurrence in scarlet fever — or a true diph- 
therial inflammation may be complicated from the first or at a 
later stage, by the streptococcus, more rarely by the staphylococcus.^ 
The combination of the streptococcus with the diphtheria bacillus 
produces, as a rule, an affection severe both in its local and general 
manifestations ; but this is not always the case, and in some in- 
stances of mixed infection the course of the disease does not differ 
from that of uncomplicated diphtheria. 

[The cardiac weakness so often seen in diphtheria would seem to 
be due to degenerative changes both in the myocardium and in the 
nerve fibres of the vagus. Thomas and Hibbard^ have studied 
these changes exhaustively and attribute sudden death to the effect 
of the diphtheria toxin on the nerve structures of the heart. They 
also call attention to the opinion that the innervation of the levator 
palatse and azygos uvula is now thought to be by the vagus and that 
hence all patients with palatal paralysis should be kept in bed, 
whether or not there be any evident change in the pulse or heart 
action, on account of the possible danger of sudden cardiac failure.] 

Symptoms. — The onset of diphtheria may be acute or insidious. 
In the former case the child becomes suddenly ill, complains of cold, 
shivers, perhaps vomits, or has a convulsion. It is then found that 
the temperature is raised to 102° or 103° F., and that the child is 
drowsy, and has headache and pains in the limbs. At this time no 
false membrane may be discoverable ; but if the pharynx is to be its 
seat, there will be some redness and tumefaction of the mucous 
membrane, swelling of the tonsils, and tenderness over the glands 
behind the jaw ; or if the larynx is the primary seat of the infection, 
there will probably be some slight hoarseness, which, in association 
with the general depression, will excite a suspicion of diphtheria. 
In the insidious cases advice is usually not sought until the child 
has suffered for some days from lassitude, depression, and loss of 
appetite, although there may already be extensive membranous in- 
flammation in the throat. Not infrequently the first case in a family 
has this insidious onset, and its existence is only discovered when 

' A paper by Kanthack and Stephens should be read in this connection ; Journ. 
Path, and Bad., vol. iv., p. 45. 

2 Hewlett and Nolan (^n"f. Med. Journ., vol. i., 1896, p. 266) found, out of a 
total of 353 cases, the diphtheria bacillus pure in 216, associated with the strepto- 
coccus alone in six only, and with the streptococcus and other microbes in thirteen 
others. 

3 Med. and Surg, report of Boston City Hospital, 9th series, 1898. 



SYMPTOMS. 135 

medical advice is sought for another ohiKl, in whom tlie attack, con- 
tracteil from the first, has begun suddenly. In some eases, with in- 
sidious onset, the tirst symptom to attract attention is swelHngof the 
neck, due mainly to adenitis. Pain in the throat may not be an 
early, nor at any time a prominent, symptom. In other cases dvs- 
pliagia is the earliest sym]itom — the tonsils are enlarged ainl tiie 
fauces red and swollen, or axlematous. This condition of appar- 
ently simple inflammation may persist for several days before mem- 
brane forms. In some few cases of pharyngeal diphtheria no dis- 
tinct membrane is seen at any stage of the ease, either because it is 
not formed, or because it occupies a site not open to inspection. In 
other cases the appearances very closely resemble those of follicular 
tonsillitis. The false membrane^ which usually appears first on the 
uvula, the eilge of the soft palate, or the tonsils, is at first thin and 
semitransparent or opalescent. Later it becomes thick, and of an 
opaque white or faintly yellow color. In consistency it varies, be- 
ing sometimes tough, at others friable, but tending to be tough at 
fii*st and friable as recovery begins. 

The Client of surface covered by the membrane, and the rapidity 
with which it spreads, varies in different cases. A small patch on 
the tonsil or soft palate may have spread on the second day to the 
whole of the soft palate, tonsils, and pharynx, and extension may 
also have taken place into the nose and larynx. If removed mechan- 
ically, it is quickly re-formed. The swelling of the surrounding 
mucous membrane is usually in proportion to the acuteness of the 
local process. After forty-eight to seventy-two hours the membrane 
usually becomes detached, sometimes in flakes. In other cases it 
undergoes rapid decomposition, giving rise to a frctid odor and a 
brownish, sometimes blood-stained, secretion. In such cases deep 
ulceration may follow the detachment of the membrane. As a rule, 
when detached spontaneously, it is not reproduced, and, in mild cases, 
the mucous membrane quickly returns to its normal color, while the 
swelling disap|>ears more gradually. Some adenitis at the angle of 
the jaw is the rule in even mild cases of diphtheria. Its extent is 
proportionate to the extent of surface involved by the membrane, 
and is only so far proportionate to the severity of the attack. In the 
most severe cases, with early toxaemia, there may l)e little adenitis. 
The membrane seldom affects the cheeks. The tongue is often thickly 
furrcil, though not the seat of membrane. The temperature usually 
falls soon after the onset, and, during a moderately severe atUick, 
may not again rise above 101° F. In the most severe cases, in 
which toxemic symptoms are prominent, the temperature may be 
8u!>normal. The pulse is accelerated in ])roj>ortion to the tempera- 
ture, but in toxjemia it becomes small, weak, and irregular. 

Diphtheria may cause death, or extreme risk to life, in several 



13G ACUTE SPECIFIC INFECTIOUS DISEASES. 

ways. Of these the most frequent are : (1) The obstruction to 
respiration produeed nieehanically by laryngeal diphtheria ; (2) 
broncho-pneumonia and bronchitis, with collapse ; (3) diphtherial 
toxfemia, or the combination of this with septic tox&emia ; (4) pa- 
ralysis (a) of heart and respiration, whicli may occur early in conva- 
lescence or before it is established, or (6) general paralysis, involving 
eventually the respiratory or cardiac systems. 

The lari/nx is atfected in about one-sixth of all recognized cases of 
diphtheria,^ and the mortality is high (over 50 per cent.). The 
younger the child, the greater the danger to life. The aifection of 
the larynx may be primary ; more often it is secondary to pharyn- 
geal diphtheria. In considering the symptoms of laryngeal diph- 
theria, it is useful to bear in mind the classification of Barthez, 
althougli it is not possible in all cases to mark the several stages. 
In the initial stage the voice is hoarse, as is also the cough, which 
comes on often in paroxysms, ending in the expulsion of a little mu- 
cus. The inspiratory murmur over the chest is harsh, but there is 
no obvious laryngeal obstruction. The spasmodic stage ensues after 
an interval of varying, but usually short, duration. Respiration be- 
comes slightly embarrassed ; inspiration is prolonged, and often ac- 
companied by slight stridor and by recession in the suprasternal 
notch and at the epigastrium. The face is pale, a little dusky, the 
eyes prominent and glassy. The child is very restless and peevish. 
Presently it has an attack of suffocative dyspnoea on waking from 
sleep, or after coughing, crying, or swallowing. The attack ends, 
perhaps, in a severe coughing fit, followed by the expulsion of glairy 
mucus or a fragment of membrane. In favorable cases there may 
be only one or two such attacks, but in severe cases the intervals be- 
tween succeeding attacks become shorter, until finally a condition of 
permanent dyspnoea is established. In this — the stage of mechanical 
obstruction — inspiration is noisy, prolonged, and attended by extreme 
recession of the epigastrium, the lower part of the sternum, and the 
attached ribs ; expiration is short ; and the pause after expiration is 
absent. The pulse is weak ; during inspiration it becomes more 
rapid, and almost, or quite, imperceptible at the Avrist (jduIsus para- 
doxus). The child is less restless — the face more pale or dusky ; the 
lips purple ; the eyes prominent, fixed and glassy. There is, in fact, 
a condition of partial asphyxia, by which eventually consciousness 
is dulled, and the child dies asphyxiated. Laryngeal diphtheria may 
be complicated by membrane in the trachea and bronchi ; more rarely 
these parts are infected before the larynx. The diagnosis is difficult, 
as the symptoms suggest the onset of broncho-pneumonia ; respira- 

' In the Metropolitan Asylums Board's hospital in 1894-5 there were 6,571 eases 
of diphtheria. Of this number 1,009 suffered from laryngeal diphtheria, of whom 
519 died. 



SYMPTOMS. 137 

tion is hurried ; recessiou is not niarkod, but tlio face is pale or eya- 
nosed. In some cases casts oi^ the trachea and bronchi have hccn 
coughed up. 

Broncho-pneumonia may complicate pharvuireal diphtheria, l>nt is 
far more common as a complication of laryngeal diphtheria. It 
comes on either early, during the first two or three days, or a few 
days after tracheotomy. It is a secondary affection, due, ]n*ol)al)lv, 
in the majority of cases, to infection hv the streptococcus, l)nt, as has 
been observed above, the diphtheria bacillus may be present also. 
Bronchitis is seldom in itself an important complication of diphtheria, 
but it favors collapse of the lung in children with soft chest walls, 
wiiich is not only dangerous in itself, but tavors the onset of pneu- 
monia. The occurrence of broncho-pneumonia causes a rise of tem- 
perature, accompanied by marked increase in the respiration rate. 

When foxamia is the cause of death, it is produced either by the 
severity of the diphtherial infection or by its association with some 
other infective agent, usually the streptococcus. In the former case, 
^"xic symptoms may exist almost from the onset of the disease, or 

me on at the commencement of convalescence. There is a rise of 
tLmi)erature, and the child sinks into a condition of great depression. 
The face is pale or leaden, the lips cyanosed, the eyes are sunken, 
and there is complete loss of appetite ; yet there is no dyspnoea. 
"When the toxaemia is due to an association of the streptococcus with 
the diphtheria bacillus, septic or malignant diphtheria, the general 
symptoms are usually, from the first, of marked adynamic type. In 
its most acute form this is an exceedingly fatal disorder. There is 
much tumefaction of the pharynx ; the false membranes are volumi- 
nous, soft, and bleed easily ; the cervical glands are involved early, 
and swell to a great size. The nasal mucous membrane is usually 
infected, and the foul and infective secretion from the nostrils leads 
to excoriation and secondary infection of the upper lip and other 
parts of the face. The prostration is extreme, and the patient, in 
most cases, succumbs in two or three days. Cases of less severe type 
also occur, which run a less nipid c(»urse, in which the general jiros- 
tration is less severe, and in which, consequently, there is more hope 
that treatment, if applied early, may avert a fatal termination. 

Oirdiac fa'dfU'e is one of the most common and distressing <*auses 
of death during the early stage (fourth to tenth day) (^^ cases in 
which the larynx is spared. At this stiige it is <lue prol)ably to de- 
generative changes produced in the muscular substance of the heart 
by the toxins. The symptoms are not very well marked ; there is 
pallor, debility, or prostnitif>n, which increases gradually ; the pulse 
is small, soft, irregular; the cardiac impulse is feeble, the first 
sound soft, toneless, the second often reduplicated. Slight exertion 
produces dyspnoea, and the patient may die suddenly in attempting 



13S ACUTE SPECIFIC INFECTIOUS DISEASES. 

to get out of bed, or even in the act of sitting up. A very similar 
train of symptoms may be observed at a later stage, but sometimes 
associated with sudden attacks of dyspnoea, and attended by vomit- 
ing. In such cases it is probable that there is a neuritis of the 
vagus. Not very infrequently sudden death occurs early in the con- 
valescent stage after some trifling exertion, and it is apparently due 
to this cause. More often, however, cardiac failure occurs later in 
patients who have already suffered from more or less widespread 
paralysis or ataxy. 

Reference has already been made to the infection of the nose in 
cases of toxsemic diphtheria, but the nasal passages may be the seat 
of uncomplicated diphtheria. In such cases, which are rare, the 
membrane, present on one or both sides, is usually thick, the dis- 
charge from the nostrils is serous or muco-purulent but scanty, and 
the general symptoms are not severe. Usually such cases run a mild 
course, but occasionally the larynx becomes infected. 

Diphtheria of the conjunctiva may be primary, or secondary to 
nasal diphtheria. In cases of moderate severity there are the custo- 
mary symptoms of severe conjunctivitis, but the palpebral conjunc- 
tiva is found to be covered by a thin false membrane. In milder 
cases no false membrane is produced and the diagnosis must rest on 
the probability of infection, or on the results of bacteriological ex- 
amination. The most severe form, which occurs as a complication 
of toxic nasal diphtheria, is very grave in its local results ; extensive 
interstitial inflammation produces a kind of solid oedema of the eye- 
lids, and ulceration of the cornea ensues, with the result that even 
if perforation be escaped, corneal opacities and adhesion of the con- 
junctiva still remain. 

Diphtheria of the mucous membrane of the mouth is rare. The 
vulva is occasionally infected, usually as a complication of measles or 
scarlet fever ; the false membrane forms, as a rule, on the inner as- 
pect of the labia majora, and the anus may be affected secondarily. 
Very rarely is the prepuce or glans in boys the seat of diphtheria. 

Primary diphtheria of the skin is a rare accident, but it is not un- 
common to see excoriations or ulcerations about the nose or mouth 
infected secondarily in toxic (septic) cases. 

Many of the complications of diphtheria have already been men- 
tioned incidentally. 

Diphtherial palsy occurs in about one-fifth of the cases which 
survive the acute attack. It varies much in extent, so that two 
forms are usually distinguished — local and general. Paralysis be- 
gins usually in the second or third week, and, therefore, after the 
false membrane has cleared away and convalescence appears to have 
commenced. It may commence, however, during the course of the 
attack. When it appears early it begins almost invariably in the 



DIPHTHERIAL PALSY. l:>9 

soft palate, is often limited to it, and wonld seem to he a \oc[\\ proe- 
ess. Even in sneh eases, however, the knee-jerks nsnally disappear, 
but they may he ahsent also during eonvaleseenee in eases in which 
no palsy is observed at any time. Paralysis of the soft palate is in- 
dicated by immobility, or diminished mobility of the soft palate ; by 
the ^^ nasal tone'' of the voice; and by the return of lluids throup^h 
the nose when an attempt is made to swallow. In other cases the 
palsy extends to the pharynx, and there is added to the other symj)- 
toms a ditHculty in swallowing, and a risk of the entrance of par- 
ticles of foinl into the larynx produeino; suffocative attacks, and 
possibly pneumonia. Apart from an accident of this nature, how- 
ever, the prognosis in these limited cases is good, and wide extension 
of the paralytic symptoms is rare. The entrance of food into the air 
passages is greatly favored by palsy of the upper constrictors of the 
larynx, which, however, occurs less frequently than paresis or 
paralysis of the glottis closei*s. This defect causes the voice to be 
whispering, and deprives the cough of its explosive character, thus 
rendering it ineffective and hindering the expulsion of mucus. 
Weakness of the muscles of the mouth is sometimes associated with 
the palatal palsy, rendering sucking and even mastication difficult, 
but definite facial paralysis of one side may also occur. 

Ophthalmoplegiaj externa or interna, is not uncommon. It is 
usually an early, and may be the only, symptom of di]>htherial 
palsy, though it is sometimes followed by palatal paralysis. Ophtlial- 
moplegia interna may affect the ciliary muscle (cycloplegia). This 
causes in an emmetropic eye indistinctness of near vision, in the 
myopic eye very little disturbance of vision ; but in the hyperme- 
tropic eye, in which the focus of the lens system lies behind the 
retina so that some contraction of the ciliary muscle is needed, even 
for jiarallel rays (/. e., for distant vision), the failure of the ciliary 
I muscle may practically destroy useful vision. In acconmiodation 
I for near objects, convergence and contraction of the pupil are 
associated movements. In diphtherial palsy there may be loss of 
j myosis on convergence, or of convergence and myosis. More rarely 
, the pupil fails to react to light. Ophthalmoplegia extenia, which is 
I rarer than ophthalmoplegia interna, is in many cases associated with 
j evidence of involvement of the cardio-respiratory centres. Tiie 
occurrence r»f strabismus therefore adds to the gravity of the )>rog- 
I nosis of diphtherial palsy far more than the onset of internal ophthal- 
I moplegia. Degenerative changes, and capillary haemorrhages into 
the pf)ns, and the gray matter of the fourth ventriflo have boen 
I recognized in cases examined after death. 

I Those forms of diphtherial palsy to which the term f/rn^'raliznl is 
applie<l do not differ essentially from the more limited forms, except 
in the rapidity with which many parts are invaded ; the muscles of 



140 ACUTE SPECIFIC INFECTIOUS DISEASES. 

the head and neck, or of the lower extremities or the cardio- respira- 
tory system are, in various cases, the parts earliest or most seriously- 
involved. In the second or third week the child begins to have some 
difficulty in swallowing, and to speak with a nasal tone. Soon its 
face assumes an expression of listlessness, owing to weakness of the 
facial muscles, and the head falls forward owing to failure of the 
posterior cervical muscles. In other cases, the first thing noticed is 
that there is weakness of the lower extremities, and the child soon 
becomes unable to walk or to stand without support. This inability 
is due to paresis, but in many cases is aggravated by ataxy. In 
other cases, again, ataxi/ is the first symptom, or it becomes associ- 
ated at an early date with the palsy of cervical muscles. Cardio- 
respiratory paralysis may develop independently or in association 
with cervical palsy. Complaint is made of abdominal pain, which 
is followed by vomiting ; there is slight dyspnoea, and the pulse is 
slow. Gradually the respiration becomes more rapid, irregular, or 
sighing ; the pulse also rapid ; the face pale and anxious. A fatal 
attack of dyspnoea — spontaneous, or determined by some slight exer- 
tion, or by an effort to swallow food, or to resist its administration — 
may then easily occur. In other cases a fatal attack of cardiac angina 
occurs without obvious premonitory symptoms. Paralysis may affect 
the diaphragm or intercostal muscles, in either case imperilling life 
not only directly, but indirectly by favoring the occurrence of 
broncho-pneumonia. If the patient is at rest in bed paralysis of the 
diaphragm produces no symptoms, but may be recognized by the 
inversion of the normal movements of the epigastrium in respiration. 
When it exists, however, slight exertion causes severe dyspnoea, and 
if the intercostal muscles be weakened also, death may suddenly be 
brought about. 

The prognosis of diphtherial palsy is on the whole good. Eecovery 
is the ride, except in cases in which there is distinct disturbance of 
the respiratory or cardiac functions, and all paralysis has passed 
away in a few weeks, or at most a month or two. If paralysis of the 
pharynx does not extend after two or three days, there is good reason 
to believe that it will remain limited, and the chief danger to be 
guarded against is the entry of food into the larynx. On the other 
hand palsy of the cervical muscles or marked ataxy calls for the 
greatest care, and a guarded prognosis, since respiratory or cardiac 
palsy ensues in many cases of this type. 

The diagnosis of diphtheria is often difficult and uncertain. Mis- 
takes arise most often in cases with insidious onset, in which there 
are no symptoms to call special attention to the throat ; hence it is 
a sound rule to make an examination of the fauces a matter of routine 
in all cases. When the fauces and pharynx are the parts affected by 
diphtheria, diagnosis is, as a rule, relatively easy if a thorough in- 



DIPHTHERIAL PALSY. 141 

spection be oarrioJ out. Distinct false nienibrane on tlu' ])illars of 
the fanoes or nvnla will always raise a strong suspicion and warrant 
the immediate isolation of the patient. The same is true of well- 
marked fidse membrane on the tonsils. Acute follicular tonsillitis, 
which is occasionally met with even in infancy, may, if attended by 
a coherent muco-purulent exudation from the crypts, recall diph- 
theria, beginniuir at several ditlerent points on the tonsils ; and in 
some few cases discrete tonsillitis, both acute and sub-acute, is really 
diphtherial. Ulceration of the tonsils, usually secondary to ulcer- 
ative stomatitis, is sometimes accompanied by ulceration of the soft 
palate ; the ulcer is usually shallow, and its surface is covered by 
a yellow muco-purulent exudation ])resenting little resend)lance to 
the yellowish white, firm, diphtherial membrane. Bacteriological 
examination has shown that pharyngitis, apparently simple, is, in 
certain rare instances, really diphtherial. The occurrence of such 
cases lends support to the opinion that the safest rule to follow is 
that adopted by many who have had large ex})erience of schools — to 
regard all cases of sore throat as infectious until the contrary has 
been proved. 

In coming to a decision much assistance maybe obtained from hac- 

teriohf/icfd examination. If the clinical signs render diphtheria prob- 

jable, the detection of the diphtheria bacillus will clinch the diagno- 

isis. Under the same circumstances, however, failure to detect the 

bacillus does not disprove the existence of di])htheria, especially if 

the examinati(»n be made late in the case. On the other hand, in 

the absence of characteristic clinical signs, the detection of the bacil- 

^lus in the secretions of the throat or mouth does not warrant the 

clinical diagnosis of diphtheria, although it wrtuld render obligatory 

the antiseptic treatment of the mouth and throat, and the isolation of 

.the indivi<lual from other children. 

[Too much importance cannot be attached to the bacteriological in- 
vestigation above mentioned. Provision for such investigation is 
now made in most of our American cities by their respective boards 
of health. The technique of the examination is simple, easily carried 
lout and of great satisfaction and value to the attending physician. 
'Those who have not access to a city labr»ratory will find the ap]>a- 
|ratns and method descrii)ed by Koplik ' of practical help in making 
|a rapid diagnosis of diphtheria. It is briefiy as follows : Wi|K.' the 
throat with one of the swal>s now in general use. Distribute the 
I material thus obtained over the blood serum. Raise the tem|K'rature 
'of the incubator — the small water oven in use in all chemical labora- 
'tories for drying j)ur|X)ses — to 38° C. by means of a Bunsen burner 
or alcohol lamp. (See cut.) Place the inoculated test-tube in the 
iinenl)ator and leave for two and one-half to three hours, keeping the 
Trant. Amer. Fed. Soc., Vol. IX., 1897 ; N. Y. Med. Journal, August 1, 1896. 



142 



ACUTE SPECIFIC INFECTIOUS DISEASES. 



Fig. 9. 



temperature at 38° C. At the end of this time remove the tube, 
scrape carefully the surface of the serum, prepare cover-glass in 
usual way, stain with blue of Loeffler, mount in Canada balsam, and 
examine with oil immersion lens. The whole method depends upon 
forcing the growth of the bacilli at 38° C, the temperature at which 
they thrive best.] 

The prognosis should be guarded in all cases of diphtheria. The 
younger the child the greater the danger to life, especially through 
laryngeal obstruction. Cases which at the out- 
set appear slight, may rapidly become very 
grave ; and even in the mildest the possibility 
of subsequent palsy must be borne in mind. 
AVith regard to pharyngeal diphtheria, the 
prognosis is on the whole worse the greater the 
extent of membrane and the rapidity of its 
spread. Early enlargement of the lymphatic 
glands is also a bad sign, and indicates, prob- 
ably, a mixed infection. Persistent vomiting 
and diarrhoea are also of evil augury, as is also 
a great diminution in the quantity of the urine, 
or the persistence of more than a trace of albu- 
men. Irregularity of the pulse or failure in 
its strength indicate that the heart is becom- 
ing embarrassed, and greatly aggravate the 
prognosis. Nasal diphtheria, if accompanied 
by much sero-purulent discharge, is probably 
due to mixed infection, and the mortality of 
such cases is very high. In diphtheria of the 
larynx the prognosis is always grave, since to 
the ordinary risks of diphtheria there are 
superadded those of obstruction, and the special 
liability to diphtherial tracheitis and bronchitis, 
and to broncho-pneumonia. Progressive in- 
crease of dyspnoea, indicating growing obstruc- 
tion, or continuous dyspnoea with blanching or 
cyanosis of the face and failing pulse, in- 
dicating the onset of broncho-pneumonia, war- 1 
rants a very serious opinion as to the prospects of recovery. 

The introduction of antitoxic serum has modified materially the 
prognosis of diphtheria. The value of the remedy may be judged 
either by individual clinical experience, or by the statistical method. . 
The latter presents great difficulties in arriving at an absolutely trust- j 
worthy conclusion, because diphtheria varies greatly in the severity I 
of the toxaemia which it produces, in the danger connected with its 
local manifestations, and in the character of the epidemic. Further, i 




Incubator employed i 
making a rapid diagnosi: 
of diphtheria. 



DIPHTHERIAL PALSY. U.S 

the age of the patient and the date at whieh treatment ean he eoni- 
meneed, intiuenee the result. Certain of the sourees of error in form- 
ing a conelusion may be eUminated if the statisties deal with a sntH- 
ciently large number of cases. The statistics of the Metropolitan 
Asylums Board for 1894, the year before the introduction of anti- 
toxin (3,04-2 eases); for 1805 and 1896, the first years in -vhieh it 
was generally but not exclusively used in the hos})itals of the I>oard 
(3,529 cases and 4,175 respectively);^ and the statistics contained 
in the report for 1895 of the American Pediatric Society, dealing 
with some 5,000 cases in private practice may be quoted. From the 
statistics of the Pediatric Society a certain proportion of the milder 
cases were eliminated, and some were moribund when treatment was 
commenced. On the whole it seems fair to conclude that the statis- 
tics from both sources are somewhat less favorable to antitoxin than 
the reality. The percentage mortality in the Metropolitan Asylums 
Board hospitals in 1894, without antitoxin was 29. (> ; in 1895, in all 
cases, those with and those without antitoxin, 22.5 ; in 189(3, 20.8 ; 
the Pediatric Society, all cases treated with antitoxin, 12.3. Diph- 
theria is a much more fatal disease in children under five than at 
more advanced ages ; in the Asylums Board hospitals the reduction 
of mortality in children under two years was from ()1.9 to 4.S.5 in 
1895, and 45.48 in 1896 ; in children from two to five, from 43.7 to 
30.7 in 1895, and 26.9 in 1896. The Pediatric Society's statistics 
for the same ages give a percentage mortality of 23.3 and 14.7 re- 
spectively. The beneficial effects of antitoxin are seen most conspic- 
uously in cases which come under treatment early in the disease, as 
is shown in the following table : — 

T<ible shoicinrj the Day of Disease on which the Patient came under Trent iwnt, <iu'1 thr 

Mortality per cent. 



1 


of Disease. 


Metropolitan Asylums Board. 


American Pedi- 
atric Society. 


^H 


Without 
Antitoxin. 


All Cases With and Without 
Antitoxin. 


With 
Antitoxin. 


P 


18W. 


1895. 


1 1896. 


1895. 


' Firrt 


22.5 

27.0 
29.4 
31.6 
30.8 


11.7 
12.0 
22.0 
25.1 
27.1 


! 4.7 
12.8 
17.7 
22.5 

i - 


4.9 


- nd ... 

Ml 

rth... 

ii and 


over 


7.4 

H.8 

20.7 

35.3 


, i, 11 Known 


/•'•• 


8.2 



\ 'Not all the ca.ses in the Asylums Board hospitals were treatoil with antitoxin. 
i Thof»e which were moribund at the time of admission, and a larjje pro|>«»rtirm <»f the 
* milder cases (together numbering 1,.347 ) were not so treate<l ; in comparing the HtaliH- 
tics it seems just therefore to take the whole series of ca.<»e« for 1895 and 181W). 



144 



ACUTE SPECIFIC INFECTIOUS DISEASES. 



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DIPHTHERIAL PALSY. 145 

Opinion foiuuled on clinical observation is, almost without excep- 
tion, lavorablc to the influence of antitoxin, if its use can l)e com- 
menced during the iirst three days of the disease. It produces an 
amelioration of the general symptoms attendeil usually by a fall of 
temperature and return of appetite. It stops the spreail of the mem- 
brane, and leads to separation of that already formed, rnder its use 
the proportion of cases in which the larynx is atVcctcd secondarily is 
diminished, and when the larynx has already become afl'ected it ren- 
ders the case less severe, diminishes the danger of suffocation, and 
causes the results after intubation and tracheotomy to be better. In 
the Asylums l>oard hospitals the mortality after trachcotomv fell from 
70.4 to 41>.4 in 1895, and 41.0 in 18JI(i ; while the percentage of 
laryngeal cases in which traciieotomy became necessiiry fell from ;")(> 
to 45.3 in 1805, and 41.0 in 189G. The statistics of the American 
Petliatric Society show a uKn-tality of 25.9 per cent., after intubation 
in cases treated with antitoxin, as against 51.1) percent, after intuba- 
tion combined with calomel fumigations which had previously given 
the best results. 

[More recent statistics confirm still further the value of antitoxin 
and emphasize the innx>rtance of early administration. The report 
of the Chicago Board of Health for February, 1<S99, is of special 
interest and shows how life can be saved by antitoxin even under 
the most adverse circumstances. The records given below arc based 
exclusively upon the results in cases of the city poor living in un- 
hygienic surroundings and treated by members of the ]>oard of 
Health, esjx'cially assigned to this work. 

A study of the above table shows a record of 4,071 cases of true 
diphtheria treated during a i>eriod of 41 consecutive months, with a 
mortality rate of G.77 per cent., and of 418 cases treated in 4 
months with a mortality of 4.11 per cent. 

The low mortality among cases treated on the first day, only 0.28 
per cent., gradually increasing to 1.67 per cent., 3.77 per cent., 
11.39 jx?r cent., and 25.37 per cent, on the second, third, fourth, 
and later days respectively, shows the great importance of early ad- 
iin'nistration. 

The second table given below shows the result of treatment by 
_es and by day of disease for four consecutive mf)nths. 

Nine \H'Y cent, of these cases, or 38 in number, rf'<|uircd intuba- 
tion, with 30 recoveries and 8 deaths, a mortality of 21 per cent.] 

With regard to the influence of antitoxic serum on compticationny it 

-lust be observed that the fact that a larger proportion of serious 

ases survive must tend to increase the proportion <A' complications. 

This is especially the case in regard to the nervous system, and the 

statistics at present available tend to show that the |ii'(>portion of 

ises in which paralysis ensues is not diminished, if indeed it !>e not 

10 



146 



ACUTE SPECIFIC INFECTIOUS DISEASES. 



Table of Results of Treatment, November', December, 1898-January, February, 1899 : By 
Ages and Day of Disease. 



Total Treated by Ages. 


Day of 

Disease 
when first 




Recovered. 


Over 10 


Died. 


Under 


lto5 


5 to 10 i Over 10 


Under 


lto5 


5 to 10 


Under 


lto5 


5tol0 


Oven 


1 year. 


years. 


years. 


years. 


treated. 


1 year. 


years. 


years. 


years. 


1 year. 


years. 


years. 


years. 


2 


16 


7 


6 


1st dav. 


2 


16 


7 


6 










9 


48 


20 


21 


2d day. 


9 


47 


20 


21 










7 


53 


39 


15 


3d day. 


7 


50 


38 


15 




3 






7 


43 


37 


13 


4th day. 


5 


39 


36 


13 


2 


4 


1 






29 


34 


17 


Later. 




25 


26 


16 




4 


6 

7 




25 


189 


137 


72 


Totals. 


23 


177 


127 


71 


2 


11 





Mortality 8 i> 



5.25 



increased. Sevestre ^ believes that while early localized paralyses 
(palate) are not less frequent, cases of generalized paralysis are more 
rare. Injection of the serum is followed in a considerable propor- 
tion of cases by slight temporary albuminuria. On the other hand, 
there is no adequate ground for the assertion that the use of anti- 
toxin is followed by an increase in the proportion of cases in which 
nephritis occurs as a complication. In some cases in which albu- 
minuria exists before the injection, it diminishes rapidly ; in others, 
it remains uninfluenced. In a large proportion, approaching one- 
half, the injection is followed by a rash. In some cases the rash 
appears on the third, fourth, or fifth day ; it is then usually urticarial, 
and disappears in a few hours or a day or two at most. In other 
cases a rash comes out from the twelfth to the fourteenth day. This 
is sometimes very extensive, resembling the eruptions of scarlet fever, 
measles, or septicaemia. It is often accompanied by pyrexia which 
may persist for several days. Occasionally pyrexia occurs without 
rash. Joint pains, sometimes severe and aggravated by movement, 
but not accompanied by obvious effusion, and lasting only for a few 
days, occur in a small proportion of cases. Abscess at the site of 
injection is rare, and appears always to be due to some failure to 
secure asepsis. 

Since the results are much better when the injections are made j 
early, the first injection should be given as soon as the diagnosis is i 
made. The needle, and all parts of the syringe, must be sterilized 
by placing them in cold water, which is then raised to the boiling- I 
point, and the apparatus is boiled for five minutes, removed from i 
the water with sterilized forceps, and placed to cool ^ on a piece of 
boracic lint, or a clean napkin. The serum should be quite clear, | 
and if possible, recently prepared, though even when a year old its i 
properties may be unimpaired. The injection is made into the sub- 1 



' "Traite des Maladies de I'Enfance" (de Grancher, Comby, et Marfan), t. i. 
2 The serum may be coagulated if the syringe is used while hot. 



640. 



DIPHTHERIAL PALSY 



147 



cutaneous tissue of the flank bv picking \\\) a fold of skin and thrust- 
ing the needle through the true skin. The skin is prepared by 
washing with soap and water, and bathing with sublimate 1 in 1,000, 



Fici. 10. 






IXpbtberial infection of uvula ami aiucrior pillar^ of fauces, hhowing the disappearance of the 
emhrane after injection of antitoxic serum (a, 18 hours ; b, 24 bourM, and c, .'iG hour,«i after injec- 
m). (From drawings by I)b. Rowland Pollock.) 



after which it is covered with absorbent cotton. After tlic injection 
• the pad of cotton-wool is replaced, and retained In' a bandage. The 
syringe is cleansed with cold sterilized water. For children under 



148 ACUTE SPECIFIC INFECTIOUS DISEASES. 

two years, and in mild cases over that age, the first dose should 
be 1,000 units; in severe cases above that age, 1,500 to 2,000. 
If there be no improvement, the dose should be repeated in from 
eighteen to twenty-four hours, or in bad cases even earlier, and a 
third dose may be given if necessary. 

In those cases in which the serum produces its characteristic eifect, 
the false membrane becomes in five or six hours whiter and more 
prominent, and is surrounded by a zone of deeply injected mucous 
membrane. The false membrane begins to become detached after 
about twenty-four hours or a little later, and is separated on the 
second or third day (Plate I.). After the injection of the antitoxic 
serum there is frequently a rise of temperature (1° to 3° F.) ; the 
maximum is reached in four or five hours, and a decline begins six 
to ten hours later, so that on the second day the temperature is 
normal. The pulse rate rises also, and often does not fall for several 
days. The eifect on the general symptoms is parallel ; there is at 
first some aggravation of the malaise, but after twelve to eighteen 
hours this begins to diminish, and at the end of twenty-four hours, 
if the injections have been given soon after the onset of the disease, 
the patient looks and feels much better. In cases of mixed infec- 
tion the change in color is less marked, the separation of the mem- 
brane less early, and less complete, and the eifect on the general 
condition of the patient slight or wanting. 

The general treatment of diphtheria resolves itself into the attempt 
to conserve the strength of the patient. The disease is of an ex- 
tremely exhausting and depressing character, and the first essential 
is rest. This cannot always be obtained by the same means, and 
every case must be considered for itself. As a general rule the 
patient should be kept in bed, and as much as possible in the re- 
cumbent attitude. The room in which the child is nursed should 
be large, well-ventilated, and have as little furniture as possible. 
In serious cases good nursing is very important. Food should be 
given in small quantities at frequent intervals, but this is in too 
many cases a counsel of perfection, and we must be content to give 
as much as the child will take without resistance or struggling or 
choking, which are to be avoided. It will often be necessary to 
supplement the food taken by the mouth by nutrient suppositories. 
Alcohol is generally well borne in cases in which there is much de- 
pression, but it must be given freely. Adynamia must be treated 
on the general principles stated in Chapter V. 

In the treatment of diphtherial palsy the main indications are rest 
and careful feeding. Soft but not too liquid food is to be preferred, 
and it is a good plan to induce the child to take its food while lying 
face downwards. In extreme pharyngeal paralysis it may be neces- 
sary to administer liquid food through the nasal tube. Signs ot \ 



DIPHTHERIAL PALSY. 149 

respiratory failure must be eonibatod by hypodermic injections of 
strvchnine, inlialations of oxygen, and absohite repose ; of cardiac 
failure by camphor, ether, or other stimulant injections. It is the 
custom to give strychnine in all ciises of diphtherial palsy, though 
in the milder, limited cases it is not necessary. Nourishing food, 
iron, cod-liver oil, are of use during convalescence, -which is usually 
protracted, a condition of feeble health remaining usually for some 
months. Change of air M'ill be of advantage if not taken too soon, 
and if the patient be guarded against fatigue. Prolonged rest for 
body and mind should be insisted upon ; and, as a rule, a child 
should not be allowed to attend school until the knee-jerks have 
returned. 

The local treatment of pharyngeal diphtheria which has been 
much followeil, has had in view two objects — the destruction or dis- 
infection of the false membranes, or the disinfection of the general 
cavity of the mouth and pharynx, with the hope of preventing de- 
composition and secondary infection. For the first purpose the list 
of caustic, astringent, or disinfectant drugs used is very long. To 
be effectual the solutions used must be strong, and must be applied 
accurately to the aifected ])art. To do this the child must be com- 
pletely uuder control, and the operator must be certain that he has 
all the surface covered by membrane under inspection. Practically, 
in young children these ends cannot be attained, and the attempt to 
make local applications excites terror and resistance, so that it be- 
comes very diHicult to ensure that the affected parts are completely 
and exclusively medicated. As Jacobi has well said, ^' There are 
cases which do not show the harm done. The fact is, that neither 
the galvano-cautery, nor carbolic acid, nor tannin and glycerin, nor 
perchloride or subsulphate of iron can be applied with leisure and 
accuracy to the very membrane alone, except in the case of very 
docile and patient children. In almost every case the surrounding 
epithelium is getting scratched off or injured,^' and thus the spread 
of the di])htherial membrane is favored. One of the best local ap- 
plications is tincture of iodine, which penetrates the meml)rane while 
prmlucing little surrounding irritation. Loffler's solution, which is 
an alcoholic solution of toluol, creolin, and menthol, has been highly 
praised. 

[Nfenthol, 10 parts by weight. 

Toluol, 30 parts by measure. 

Creolin, 2 parts bv measure. 

Alcohol, to 100 " "' 

Appendix.] 

The most thoroughly local medication is that devised by Gaucher, 
but it is extremely painful. 



150 ACUTE SPECIFIC INFECTIOUS DISEASES. 

[Camphor, 20 parts. 
Carbolic Acid (Crystals), 6 " 

Tartaric Acid, ' 1 *' 

Castor Oil, 15 *' 

Alcohol (90 degrees), 10 *' 
Dissolve the carbolic acid in the alcohol, add the camphor, then the tartaric acid, 
and lastly the castor oil. Appendix.] 

A large number of small absorbent cotton swabs are prepared ; 
several of these are used in succession to remove the false membrane 
as far as possible ; next a strong solution of camphor and carbolic 
acid in spirit and castor oil is applied very thoroughly to the denuded 
surfaces ; and, finally, after an interval of ten minutes, the throat is 
washed out by a stream from an irrigator so regulated as to be strong 
enough to excite forcible contraction of the pharynx, and thus prevent 
deglutition. About three pints of liquid, which may be simply boiled 
water, or carbolic acid 1 in 100 should be used. The process must 
be repeated every three or four hours. It is extremely trying to 
adults, and obviously inapplicable to young children. Short of this, 
however, it is very doubtful whether local applications with a brush 
or swab will effect any more than the use of sprays and douches, 
which can be much more easily applied. They assist in the removal 
of shreds of membrane, check decomposition in the mouth, and when 
rendered astringent, diminish the tendency to catarrh. For this pur- 
pose solutions of carbolic acid 1 in 100, of salicylic acid 1 or 2 in 
1,000, of boric acid (saturated), of perchloride of mercury 1 in 5,000, 
or of potassium permanganate 1 or 2 in 1,000 may be used. The 
main point is to use a large quantity of the solution, and to see 
that the stream is sufficiently strong to excite reflex contraction of 
the pharynx, so that most of the solution is returned through the 
mouth. The child must be held firmly by an assistant, with the 
head bent forward, and the mouth be opened sufficiently, and the 
tongue so far depressed as to ensure to the solution free access to the 
pharynx and egress from the mouth. For nasal diphtheria, anti- 
septic solutions must be injected into the nostrils, or where this is 
difficult, owing to the age of the child, the spray may be used. The 
nozzle of the syringe should be covered by a piece of india-rubber 
tubing and the injection thrown directly backward. As much of 
the fluid injected is swallowed, it is not advisable to use poisonous 
drugs, such as perchloride of mercury. 

In laryngeal diphtheria local applications are, practically, out of 
the question in children, but much relief may be afforded by keep- 
ing the child constantly in moist, warm atmosphere (steam). A 
steam tent should be used, but if some relief is not obtained in a 
few hours it is not, as a rule, desirable to persevere. [Where the 
symptoms of laryngeal diphtheria are so severe as to require surgical 
interference, the operation of election is now universally conceded to 



DIPHTHERIAL PALSY. 151 

be intubation, tracheotomy being reserved for those cases in which 
intubation has been tried without success.] 

Of the multitude of drugs recommended for internal administra- 
tion the best are the tincture or solution of perchloride of iron in 
pharyngeal diphtheria, and perchloride of mercury when the larynx 
is affected. In either case the drug must be given in small doses 
frequently repeated, the iron salt every half-hour or hour, in such 
doses that an infant takes 3j to oiss, during the twenty-four hours, 
the mercurial hourly, so that gr. J is taken during the same period. 
The dose should be reduced after a few days. Children of three 
years will take twice this quantity. 

\_LninunizaUon. — There can to-day be no doubt of the value of 
immunizing doses of antitoxin given to those exposed to diphtheria, 
and all such should receive at the earliest possible moment an 
amount of the serum varying with the age of the individual from 
50 to 500 units. An infant under three months should receive 50 
units ; from five to ten years the dose is 200-400 units ; above ten, 
500 units. The length of time for which immunity will be con- 
ferred by these doses is variously stated at from ten to twenty days.] 



CHAPTER IX. 
MALAEIAL FEVER. 

The Hiematozoon — Varieties of Malarial Fever : Quotidian ; J^stivo-autumnal ; 
Pernicious — Malarial Cachexia — Diagnosis — Prognosis — Treatment. 

Malarial fever is due to infection by the hsematozoon first de- 
scribed by Laveran in 1880. Different clinical types of malarial 
fever correspond to certain morphological peculiarities of the associ- 
ated parasite, which may perhaps indicate specific differences. Two 
main varieties may be distinguished : (1) the parasite of simple in- 
termittent fever (a) tertian, (6) quartan ; and (2) the parasite of 
irregular, grave (sestivo-autumnal) fever. While in the human body 
the h^ematozoon is in all varieties and at all stages of its career, ex- 
cept that of free spore, an intra-corpuscular parasite. The tertian 
and quartan parasites pass through a series of changes in the red 
blood-corpuscles, ending in a process of segmentation and the forma- 
tion of spores, which, on being set free, invade a fresh set of cor- 
puscles, and the cycle commences again. In the case of the tertian 
parasite the cycle occupies forty-eight hours, of the quartan seventy- 
two hours. A quotidian fever, that form most often seen in children, 
is produced by a double tertian infection, segmentation taking place 
on different days ; or, more rarely, by a treble quartan infection. 
The characteristic paroxysm of malarial fever corresponds with the 
breaking up of the parasite and the escape of the spores into the 
liquor sanguinis on the completion of the cycle by the process of 
segmentation. The development of the parasite of the sestivo- 
autumnal fever, though often approximately tertian, is less regular, 
being sometimes apparently quotidian. Segmentation takes place, 
probably, in the spleen, bone-marrow, brain, and viscera, rarely in 
the peripheral blood. The fever is often irregular, the paroxysms 
sometimes imperfectly marked, and the remissions often incomplete. 
The symptoms produced by malarial infection must be attributed, in 
part, to the actual destruction of the infected corpuscles, and in part 
(fever, etc.) to toxins which are assumed to be liberated in the blood 
in the breaking up of the parasite after segmentation. 

Opinions differ as to whether infants and children are more or less 
liable to suffer from malaria than adults, the truth being, in all 
probability, that the liability is the same. Malaria may occur at 

152 



MALARIAL FEVER. 153 

anv age, and has been observed so soon after birth (eighteen hours) 
that the infection must have been intra-uterine. 

In children over the age of about six years, the symptoms of 
malarial infection present no characters to distinguish them from 
those observed in adults, but in infants and young children the 
paroxysms are less regular, the mode of onset more insidious, and the 
risk to life greater. The attacks are usually quotidian, but the 
paroxysms are not so well marked, and the remissions are less com- 
plete than in a typical case in an adult. The cold stage is not usually 
marked by definite rigors, but the infiint vomits, becomes blue about 
the lips and hands, and is peevish or strikingly somnolent. Occa- 
sionally, convulsions are the first symptom, but frecjuently the 
symptoms of the first stage are so little marked that the infant is not 
noticed to be ill until the febrile stage begins. When this is estab- 
lished the face is flushed, the surfiice puugently hot, and the temper- 
ature 104°, 103°, 106° F., or even higher ; after two to eight hours 
the febrile stage ends, and the temperature falls considerably, but not 
always to normal ; profuse perspiration, usually observed in adults at 
this stage, is seldom or never observed in infants and young children. 
The spleen, after one or two attacks, will be found to be enlarged in 
nearly all cases. In those cases in which the onset is insidious, the 
patient becomes languid and peevish, loses appetite, complains of 
abdominal discomfort, and there is often diarrh(ea. The spleen and 
liver will l)e found to be enlarged, and the skin has an earthy yellow 
tint. Some continuous pyrexia is present with, perhaj)s, irregular 
fluctuations ; after a time the exacerbations grow more severe, the 
remissions more pronounced, and a quotidian type of fever becomes 
distinguishable. In such cases, gastro-intestinal disturbance of 
various kinds, but especially obstinate diarrhoea with mucous stools, 
is common. Unless suitable treatment be adopted at an early date 
malarial infection quickly produces a profound deterioration in the 
child's health, and the patient becomes emaciated, sallow, and ex- 
tremely aniemic. In such a condition, it may easily succumb to 
some intercurrent infection. 

The pernicious forms of malarial fever api>ear to be comparatively 
rare in children. Occasionally, however, infants after one or two 
paroxysms, suddenly pass into a comatose condition with high tem- 
perature or hyperpyrexia ; in older children, eclampsia during the 
f<^*brile stage marks a severe form of infection. 

Repeate<l attacks of malarial fever, or prolonged residence in a 
malarial district, even without distinct attacks, may lead to the de- 
velopment of a condition of maldrial cfirhcriff characterized by wast- 
ing, anaemia, and enlargement of the spleen, which may attain an 
immense size. The patients suff*er also from intestinal catarrh, 
oedema of the extremities, petechiie, and epistaxis. In children who 



15J: MALARIAL FEVER. 

have suifered from ague various neuralgic pains may occur and lead 
to errors in diagnosis unless their malarial origin be recognized. 
Frontal headache is a common symptom, and if associated with 
drowsiness, vomiting, and constipation, as is sometimes the case, may 
lead to a suspicion of tuberculous meningitis. 

The (Jiag)wsis of malarial fever may be made by a recognition of 
the ha?matozoon in the blood ; apart from this it must depend upon 
a history of residence in a malarious district, the periodicity of the 
symptoms, the enlargement of the spleen, the effect of quinine, and 
upon the exclusion of other conditions which could account for the 
fever or other symptoms. If the blood be not examined, it may be 
very uncertain, and there can be no doubt that in countries in which 
malaria prevails, very many cases are attributed to its influence upon 
very slender grounds. The attempt to distinguish the severer forms 
from typhoid fever was, at one time, in many districts altogether 
abandoned ; the examination of the blood for the malarial parasite, 
and the serum test for typhoid fever w^ll set many doubts of this 
kind at rest. Further, the temperature curve of malarial fevers 
during the first week is never so regular as that of typhoid fever, 
and the exanthem does not occur. From tuberculosis there may be, 
as already said, temporary hesitation in distinguishing the more 
irregular forms of malaria, but the effects of treatment will gener- 
ally set such doubts at rest, and the same remark applies to the 
irregular fever of pysemia, in which, moreover, some initial lesion 
will usually be discoverable. 

The prognosis is good except in those cases in which the symptoms 
develop with great rapidity and the patient quickly becomes comatose. 

The treatment of malaria consists in the main of the proper ad- 
ministration of quinine ; it has the effect of causing all forms of the 
parasite, with the exception of the crescent body, to disappear from 
the blood. Given some hours before a paroxysm it w^ll stop not 
that paroxysm but the next. In young children, in whom the peri- 
odicity is not often well marked, it is perhaps best to give the amount 
considered appropriate in divided doses during the twenty-four hours. 
Except that the bitterness of the drug leads them to dislike taking 
it, infants and children tolerate quinine well, and in ordinary cases 
an infant may be given at once gr. ss to gr. j, three times a day, in- 
creased rapidly if the desired effect is not produced ; in mild cases, 
however, as good an effect will be obtained with the smaller dose. It 
may be given in solution with syrup of orange, or if there is much 
repugnance to it, in powder suspended in a teaspoonful of milk. 
Vomiting is sometimes exceedingly troublesome, and quinine may 
be given by the rectum, either by enema to which a drop of tinc- 
ture of opium is added, or better, in a cocoa-butter suppository; the 
dose should be double that given by the mouth. If other expedi- 



TREATMENT. 155 

ents fliil, it may become necessary to give the drug by hypodermic 
injection. In the pernicious forms in which the patient is comatose, 
and in which it is important to produce the etFect as rapidly as pos- 
sible, the same method must be resorted to from the first. For hy- 
podermic injection the best salt is the hydrochlorate or the hydro- 
bromate. The injection (gr. ss to gr. j), should be made deeply in 
the buttocks or back. 

^lalarial cachexia, if it have not reached too advanced a stage, will 
usually improve under the administration of iron and arsenic, care- 
ful dietinir, and removal to a non-malarial district. 

[Malarial fevers occur in this country in southern Xew England, 
along the Atlantic Coast south of New York, in the Gulf States 
and in the Mississippi Valley ; in the last-named region severe forms 
are met with. ^lild forms of the disease also occur about the Great 
Lakes, in the Middle States and on the Pacific Coast. 

Thayer thinks that the more irregular course of malaria in chil- 
dren is probably due to " infection with multiple groups of the para- 
sites or to the lack of arrangement of the parasites in well-marked 
large groups.'^ He also thinks that the chronic malarial cachexia 
so common in young children and infants is due to failure to recog- 
nize the disease and consequently improper treatment. 

Examination of the blood for the parasite should always be made 
in the obscure irregular fevers of early life.] 



CHAPTER X. 
TUBERCULOSIS: ETIOLOGY; PATHOLOGY. 

The Tubercle Bacillus — The Tuberculous Diathesis — Sources of Infection — Milk — 
Predisposing Diseases — Sites of Primary Infection : Xaso-Pharynx and Cervical 
Glands ; Ear ; Intestines — Varieties of the Tuberculous Process — Age Incidence 
— Prevalence of Tuberculosis in Childhood — Sex. 

Etiology. — Two factors have to be considered, the susceptibility 
of the individual and the opportunities for infection. The impor- 
tance of the former has been alternately exaggerated and minimized. 
While it is certain that tuberculosis cannot occur in the absence of 
the specific infective agent — the tubercle bacillus — it is equally cer- 
tain that under favorable circumstances the human organism, whether 
that of the child or of the adult, is able continuously to destroy 
tubercle bacilli which enter the lungs or intestines in small numbers. 
This must occur with great frequency in all populous places. 

A circumstance which has much influence in increasing the sus- 
ceptibility of the individual is the inheritance of a special type of 
constitution, the so-called tuberculous diathesis. The main causes 
diminishing the power of resistance are over-crowding, insanitary 
surroundings generally, and malnutrition. Deficient ventilation of 
living rooms has a double action, since it tends to deteriorate the 
general health, while at the same time it increases the chances of 
aerial infection. 

The main sources of infection, in the child as in the adult, are 
through the air and through food. The risk of infection of the 
lungs and air passages by the tubercle bacillus disseminated through 
the air by the pulverization of dried sputum, is well known and need 
not be discussed here. AVhether children are more or less liable 
than adults to infection in this way may be left an open question, 
but there is strong reason to believe that they are more liable to in- 
fection, or, at least, more often infected through food, owing either 
to a lower power of resistance or, more probably, to the fact that one 
of their main articles of food — milk — is specially liable to carry the 
infection. Tuberculosis is a very common disease of milch cows, 
but their milk only becomes infective when the udder is the seat of 
tuberculous disease. According to Sidney Martin ^ " the milk of 

^ "Keport of the Royal Commission on Tuberculosis," part iii. (1895), p. 39. 

156 



il 



ETIOLOGY. 157 

cows ^vith tuberculosis of the udder possesses a virulence which can 
only he described as extraordinary,'' and is unfit for human con- 
sumption. AVoodhead ^ has pointed out that such milk, when added 
ven in small quantities to milk from a healthy source, can impart 
lo it infectious (lualities. In exceptional cases tuberculosis is truly 
congenital, the infection having taken place during intra-uterine life. 
In a few cases infection has taken place through the skin, as in the 
rite of circumcision, or from saliva used for the lubrication of ear- 
rings, or for mixing the paint for tattooing. Possibly the habit 
which most infants and young children have of ]>utting every object 
which they pick up into their mouths may occasionally be the mode 
f infection. 

Among prc(Ui<posiiif/ causes mention must be made of certain dis- 
uses. Of the acute diseases, the most important in this connection 
are measles and whooping-cough ; of the chronic, catarrh of the 
respiratory and gastro-intestinal mucous membranes. As in the 
adult, catarrhal affections of the bronchi and lungs are often fore- 
runners of tuberculosis. The epithelial degeneration thus produced 
doubtless favors the development of the specific infection. It is 
"wing, probably, to their proneness to produce catarrh and lympha- 
denitis that measles and whooping-cough so frequently determine the 
'•nset of tuberculosis; but in other cases they act by rousing into 
activity glandular tuberculosis, already in existence, but in an abso- 
lescent or latent stage (Gcill). 

There is good reason to believe that in children infection takes 
jdace, in some cases, through the nasojyhari/nx. It w^ould appear 
that in them the tubercle bacilli can be carried from the lym])hoid 
tissue of the tonsil and pharynx to the cervical lymphatic glands, 
even thoncrh there be no obvious tuberculous lesion of the mucous 
membrane. To this mode of infection is probably due the chronic 
tuberculous adenitis of the neck (strumous glands) so common in 
early life. The after course in these cases varies greatly. In 
some, probably in tlie majority, the disease does not become gen- 
eralized. In others, general tuberculosis ensues, and has been known 
• follow the operation of scraping out the enlarged glands. In 
others again, the infection descends from gland to gland, until it 
reaches the lymphatic glands at the root of the lung, or the pU^ura 
near the apex, or both. From these situations tlic lungs become in- 
volve<l by extension. Woodhead, arguing from tlie result of feeding 
xjK'riments,^ expresses his belief that this method of infection of the 

« /6.V/., p. 14l». 

'Especially in the pijr, which in itn omnivorous diet, if nf»t, as the pre-Vesalian 
anatomists afliected to believe, in structure also, is "likeliest the human form divine." 
He says, referring to this animal (Lfinrrt, 1H94, vol, ii., p. 9oS) : " In many f»f these 
cases the process can Ik? tracefl from the glands in the tonsil down into the neck, and 
so on to tne thorax by the metliastinal and pfjst-Htemal glaiuls, and by the intercostal 



158 TUBERCULOSIS. 

glands of the neck through the tonsils must be of comparatively fre- 
quent occurrence, especially in children living under insanitary 
conditions and subjected to various devitalizing influences. 

In this connection it may be pointed out that tuberculous disease 
of the ear is probably by no means uncommon in children, and es- 
pecially in infants, Korner^ states that frequently at the post-mortem 
examination of children who have died of general tuberculosis, there is 
found, along with suppuration of the tympanic cavity and caries, or 
necrosis of the temporal bone, tuberculous menigitis, or tubercle in 
the substance of the brain, and points out that Henoch lays stress on 
the frequency of the combination of caries of the petrous portion 
AAdth intracranial tuberculosis. In some cases the tuberculosis of the 
ear is only a part of a widespread tuberculosis, but in others it ap- 
pears to be the starting-point. 

Infection by tuberculous milk may take place also through the 
intestines. As in the case of the pharyngeal lymphoid tissue, the 
small wandering cells of the lymphoid patches of the intestines take 
up the tubercle bacilli ; under favorable circumstances, that is to say, 
in a vigorous individual, or when the number of bacilli is small, they 
are destroyed by the cells, but if they escape destruction one of two 
things may happen : they may develop in the lymphoid patches, pro- 
ducing tuberculous ulceration ; or they may be carried by the wan- 
dering cells to the mesenteric glands, leading to an enlargement and 
finally to caseation of these glands (tabes mesenterica). It is not 
always the nearest glands which become infected. The bacilli suc- 
ceed in running the gauntlet of the first chain. The bronchial 
glands, and finally the lungs, may become infected secondarily. 
Thus Woodhead writes,^ " I have seen in case after case in children, 
and in animals fed on tuberculous material, the lungs markedly af- 
fected ; but in a large proportion of these cases it has been possible 
to trace the course of invasion back from a caseous or old calcareous 
mesenteric gland, through the chain of retro-peritoneal glands, up 
through the diaphragm to the posterior mediastinal and bronchial 
glands, and so on to the lung. I have not seen this in a few cases 
only, but in dozens of children, in a few adults, and in many ani- 
mals." The same observer believes that in infants primary infection 
of the lungs may take place occasionally by the direct entrance of in- 
fective tuberculous material derived from milk into the respiratory 
passages.^ Tuberculous infection of the alimentary canal by meat 
contaminated with tuberculous material, which has been shown to be a 

lymphatics and glands, and it is interesting in such cases to note how the lungs may 
be perfectly healthy, until the glands at their root, or in the pleura, have become 
diritinctly affected." 

^ Die otit. Erkrank. d. Hirns, etc., 1896. 

2 Lancet, loc. cit. , p. 960. 

^ "Royal Commission on Tuberculosis," 1895, part iii. 






AGE IXCIDENCE. 159 

very rare event at any age, must be extremely infrequent in infancy, 
and probably not much more common in childhood. It has been sup- 
posed that the practice of giving grated raw meat to infants might be 
responsible for producing intestinal infection, but this can very rarely 
occur even when beef is used for this purpose, and the danger may 
be obviated by employing mutton in its place. 

Pathology. — It is not necessary in this work to describe the char- 
acters of the bacillus tuberculosis, nor the minute anatomy of the 
lesions to which it gives rise, since these subjects are now dealt with 
fully in all the text-books of medicine. In childhood, tuberculosis 
is more prone to be generalized from the first, or to become general- 
ized at an early stage of a local infection, and the distribution of 
tuberculous lesions in childhood differs from that usually met with at 
adult ages. The lymphatic glands, the bones, and the meninges are 
affected more often during the first ten years of life than at any sub- 
sequent age. The severity and acuteness of tuberculosis varies 
greatly ; this variation depends upon the degree of susceptibility of 
the individual, the mode of infection, and probably upon differences 
in the virulence of the bacillus from different sources.^ Thus we 
have at one end of the scale acute tuberculosis, and at the other 
lupus, with many intervening types, of which scrofulous disease of 
bones and glands is the most definite. 

Age Incidence. — Congenital tuberculosis has been observed, but it 
is so extremely rare that Virchow has never met with an instance. 
Straus" states that, in spite of the great amount of attention directed 
to the question, the opinion expressed by Cohnheim in the following 
words still remains true : ^' The number of indisputable cases of 
congenital tuberculosis is extremely limited, and can be counted on 
the fingers.'^ In all well-authenticated cases the mother has been 
tuberculous. 

Tuberculosis is rare under the age of three months, and is not 
often met with under six months ; it then becomes more common, 
and is extremely fatal in the second year of life. Hutinel found that 
3.5 per cent, of the infants under one year who dicd^ in the Hopital 
des Enfants-Malades were tuberculous. ^^ Very different," he adds, 
" are the proportions after the first year ; at the Hospice des Enfimts 
Assistcs a third of tlie children Ijctween one and two years present 
tulx?rculous lesions." Statistics from Kiel and Munich appear to 
show that, so far as a conclusion can be drawn solely from post- 
mortem observation, the liability to tuberculosis increases very rapidly 

'The Report of the Mffliml Ojjirer of the Local Government Record for 1H88 contains 
a report by I>r. Lingard on the relations of scrofula, lupus, and tuberculosis, w lii<li 
affords exj>erimental evidence on this point. 

« " \ji Tuberculose et son Bacille," Pari.s, 1895, p. 530. 

^ I>nring 1800, Straus, loc. cit., p. 532. The Kiel and Munich statistics are quoted 
from the same author. 



160 



TUBERCULOSIS. 



in the second year of life, and then progressively, 
together are as follows : 



The figures taken 



Age. 


Number of 
Post-mortems. 


Tuberculous. 


Percentage Tuber- 
culous. 


0- 1 


1,487 

1,053 

333 

236 


67 
303 
117 

91 


4.5 


1- 5 


29.8 


5-10 


35.1 


10-15 


38.6 







These figures, however, do not indicate the relative importance of 
tuberculosis as a cause of death at various ages, but rather the fre- 
quency of tuberculous lesions, from many of which recovery might 
have been possible under more favorable conditions of general health. 
It is important to form an opinion as to the relative importance of tu- 
berculosis as a cause of death at various ages, because such knowledge 
will be of use in considering the subject of prophylaxis, and also in 
diagnosis, when, as is often the case, the signs and symptoms do not 
at once warrant a confident expression of opinion. The best statis- 
tics in this connection are probably those of Holsti, for the town of 
Helsingfors and its suburbs.^ The number of deaths from tubercu- 
losis during the years 1882-89 was 1,771. The following table 
shows the age-distribution, and also the proportion to 10,000 per- 
sons living at each age : 



Age. 


Number of Deaths. 


Mortality per 10,000 Living.' 


0- 1 


215 

180 

129 

42 

20 

61 

156 

195 

395 

212 

108 

46 

12 


285 


1- 2 


260 


2- 5 


63 


6-10 


17 


11-15 

16-20 


8 
17 


21-25 


33 


26-30 


41 
50 


31-40 


41-50 


45 


51-60 


40 


61-70 


36 


Over 70 


20 



The table brings out very clearly the extreme liability to tubercu- 
losis during the first two years of life, and, since children under six 
months are very little subject to the disease, it indicates a rapid in- 
crease during the second six months of life. 

AVith regard to pulmonary tuberculosis, Bertillon's statistics for 
Paris show that the mortality from the disease is very considerable 
^Zeitschr.f. klin. Med., 1893, Bd. xxii., s. 317. 



PREVALENCE OF TUBERCULOSIS IX CHILDHOOD. IGl 

under five years, falls to the niininmm between five and ten years, 
and then beirins to rise, reaehino; the maximum between the atres of 
thirty and forty-five. Wiirzburg's statistics for Prussia show very 
siniihir fluctuations in chiklhood and early adult life. Those of the 
Registrar-Geneml for England and AVales show a very high rate of 
mortality from tuberculosis under five, a much lower rate from five 
to fifteen, and then a steady rise due to the increasing mortality from 
pulmonary consumption. 

As Holsti has well observed, the great mortality under two years 
of age is an indication not so much of a greater ]n*evalence of tuber- 
culous disease at that age as of the fiict that in infancy and early 
childhood it prevails usually in a form and with a localization which 
quickly cause death. Of 395 fatal cases of tuberculosis in the first 
two years of life, 265, or 67 per cent., were attributed to tuberculous 
meningitis, 81, or 20.5 per cent., to phthisis, 46, or 11.6 per cent., 
to tuberculosis or general tuberculosis, and 3, or 0.8 per cent., to 
intestinal tuberculosis. Holsti's observation on these figures — that 
while some cases of meningitis supposed to have been tuberculous 
may, in reality, have been simple, and some cases supposed to be 
general tul>erculosis may have been typhoid fever, yet many cases 
really tuberculous were probably attributed to other causes, espe- 
cially instances of tuberculous enteritis — is probably correct. 

Prevalence of Tuberculosis in Childhood. — It is difficult to 
speak with cnnfidence as to the extent to which tuberculosis prevails 
in children, for the statistics already quoted have dealt mainly with 
those who succumb to the disease, whereas there can be little doubt 
that many children suffer infection, but recover. GeilP has advanced 
s<^)me valuable evidence upon the subject, founded on the post-mortem 
ap})earances in a large number of children (at all ages under fifteen 
years) who succumbed to acute infectious diseases. His inquiry ex- 
tended to 584 cases. Almost without exception, these children had 
been in good health — that is to say, they had presented no symptoms 
of scrofulosis l)efore the onset of the acute disease — and in most there 
was before death no evidence that they were the subjects of tuber- 
culosis in any form. Post-mortem 198, or 33.9 per cent, presented 
unmistakalile naked-eye evidence of tuberculosis of one or more or- 
gans ; 384 of the children were under two years of age, and of this 
numl>er 6<>, or 21.2 jx?r cent, were affected, while of tliosc above two 
years between 46 and 47 per cent, presented tuberculous lesions. 
The exi.stence of the tuberculosis no doubt, in some cases, determined 
death, and in others, by its depressing effect on the health, con- 
tributed to bring about that result ; but, even so, the statistics afford 
evidence that a very large proportion of children, who appear to l)e 
in good health, have in reality become infected. In the majority, 

^Jahrb.f. Kinderhlkde., Bd. xxxii., s. 165. 
11 



162 TUBERCULOSIS. 

probably, the infection does not spread beyond the lymphatic glands, 
which were aifected in every one of Geill's cases. 

Sex. — The statements as to the relative liability of the two sexes 
vary. The truth appears to be that, under two years of age, there is 
a slight preponderance of males ; shortly before and after puberty, a 
preponderance of females. 



CHAPTER XI. 
CLINICAL VARIETIES OF TUBERCULOSIS. 

Tuberculosis and Scrofula — General Tuberculosis : Acute and Chronic — Tuberculosis 
of Bones and Joints — Tuberculosis of Lymphatic Glands ; the Cervical and 
Tracheo-bronchial Glands. 

Clinical Varieties of Tuberculosis. — Tuberculosis in childhood 
may be acute, and then in a large proportion of cases is either a 
general disease from the first, or becomes generalized before the ter- 
mination of the case ; or it may be chronic, and may then be general 
or localized. When at first chronic and localized it is apt — owing 
to accident, surgical interference, or some intercurrent acute disease, 
as. for instance, measles — to become generalized and acute. 

It is usual, and perhaps useful, to distinguish two types of consti- 
tution which are liable to suffer from tuberculosis in different ways. 
They have been described by Sir William Jenner in the following 
contrasted pictures : — Tuberculosis. '' Xervous system highly devel- 
oped ; mind and body active ; figure slim ; adipose tissue small in 
quantity ; organization generally delicate ; skin thin ; complexion 
clear : superficial veins distinct ; blush ready ; eyes bright, pupils 
large ; eyelashes long ; hair silken ; face oval, good-looking ; ends 
of long bones small, shafts thin and rigid ; limbs straight. Children 
the subjects of tuberculosis usually cut their teeth, run alone, and 
talk early." — Scrofulosis. ^' Temperament phlegmatic ; mind and 
bo<Jy lethargic ; figure heavy ; skin thick and opaque ; complexion 
dull, pasty looking ; upper lip and alie of nose thick ; nostrils ex- 
panded ; face plain ; lymphatic glands perceptible to touch ; abdomen 
full ; ends of the long bones rather large, shafts thick." The first 
type furnishes perhaps the larger number of cases of miliary tuber- 
culosis, of acute tuberculosis of the lungs, and of meningitis. The 
pathological characteristic of the scrofulous type is the proneness to 
inflammation of the skin and mucous membranes. Such children 
are peculiarly liable to various chronic forms of dermatitis, and of 
chronic ophthalmia, to chronic rhinitis with excoriation of the surface 
of the upper lip and thickening of its substance, and, above all, to 
chronic phar^'ngitis, and tonsillitis with consecutive enlargement of 
the cervical glands. To this type belong, probably, the larger num- 
ber of cases of tuberculous, so-called " strumous," disease of bones 

163 



164 



CLINICAL VARIETIES OF TUBERCULOSIS. 



and joints. But the ^^ tuberculous " type is by no means exempt 
from " scrofulous " disease of bones and glands, nor the scrofulous 
type from acute tuberculosis, whether general or limited to the 
meninges or lungs. 

General Tuberculosis. — General tuberculosis occurs in children 
under two forms ; (1) acute general tuberculosis, which conforms to 
the type of an acute specific fever ; (2) chronic or subacute general 
tuberculosis, in which the patient passes into a cachectic condition. 

Acute General Tuberculosis is due to a general infection involv- 
ing many organs without a preponderating affection of any one. 
Infection of the general system is no doubt derived from some pre- 
existing local tuberculous lesion, but this may not have been observed 
during life, and after death may be recognized with difficulty. The 
primary lesion is most often in the tracheal, bronchial, or mesenteric 
lymphatic glands ; more rarely in the bones, the lungs, or the kid- 
neys. General infection is in many cases, probably in the large 



Fig. 11. 



d c b 





^m^ymw^ 



i. Section of wall of small artery (intracranial) showing an early stage of tuberculous lesion, 
a, epithelium, unchanged ; 6, sub-epithelial layer proliferating, with one multi-nucleated giant- 
(.ell ; c, elastic membrane; and d, media, unchanged. (After Hektoen, Journ. of Exper. Med., 
vol. i.) 

ii. Section of small artery (intracranial), including both walls, showing a later stage. A ease, 
ous focus, /, has perforated the elastic membrane, c, and has infiltrated the media and adventitia 
so as to form an aneurysmal dilatation of the vessel. Proliferation is commencing in the sub-epi- 
helial layer, h, on the opposite side of the vessel. (After Hektoen. ) 

majority, brought about either by rupture of a tuberculous collection | 
into a vein, or by tuberculous infection of the wall of a blood-vessel, 
leading in either case to the discharge of active infective material 
into the blood stream (Fig. 11, i and ii). General infection may 
also be produced by tuberculous disease of the thoracic duct. In 
some instances the determining cause appears to be an attack of 



i 



ACUTE GEXERAL TUBERCULOSIS. 165 

nietisles, whooping-cough, typhoid fever, or, more rai-ely, other in- 
feotious disease. 

The symptoms commonly resemble those of typhoid fever. After 
a short period of failing health and loss of a|ipetite, the increasing 
weakness, signs of fever, and perhaps some wandering at night, lead 
to medical assistance being sought. The patient is found to be apa- 
thetic, the face flushed, and the tongue small, red, or irregularly coated, 
and tremulous. The general aspect is one of severe illness, for which 
physical signs do not afford suflicient explanation. The pulse be- 
comes rapid and feeble, the tongue dry, the lips cracked, and the face 
more flushed, while delirium is continuous, though worse at night. 
The course of the temperature may aflx>rd assistance in diagnosis 
owing to the fact that it seldom or never shows the regular rise and 
diurnal variations characteristic of typhoid fever. The rule is to 
find an evening rise to 102°-104° F., and a marked remission in the 
morning, but the temperature may reach the highest point at almost 
any j>eriod during the twenty-four hours, and the remissions may be 
so great that it may fall to the normal or below, and so remain for 
several days without any definite amelioration in the other symptoms ; 
thus the pulse may be rapid and the general aspect and condition 
such as to lead to the expectation that the temperature is elevated, 
whereas the thermometer may show that it is little, if at all, above 
the normal. Further, throughout the whole course of the case, even 
for three or four weeks, there may be no rise of temperature, or only 
a transient elevation. Reinhold observed this in nine out of fifty- 
two cases. The respiration is usually hurried, especially in the early 
stages, and there is often some cyanosis, though physical examina- 
tion will probably reveal, at most, signs of general bronchitis of slight 
intensity. In the latest stage the respiration may be of the Cheyne- 
Stokes type. Delirium is seldom noisy, and the child becomes more 
and more dull, until torpidity develops into coma. If intracranial 
infection ensue the delirium may become more active, and the hy- 
^ x^ephalic cry may be heard. (See " Tuberculous Meningitis.") 
:istipation is the rule, but diarrhrea may occur, and the stools may 
Mood-stainefl, though this is unusual. Enlargement of the spleen 
s not occur so early as in typhoid fever, but it may exist when the 
•■ comes first under treatment, and may eventually be considerable. 
• urine may contain a trace of albumen, and may give the diazo- 
•tion. There is no characteristic rash, but a few scattered red 
ts may appear (not in crops) ; they are irregular in size and often 
itain at the centre a swollen hair-follicle. Sometimes a very sim- 
'' appearance is produced by flea-bites, and petechije, which mayi)e 
in part to the same parasite, are often numerous, especially about 
• wrists. 
The diagnosis from typhoid fever, as will have been inferred from 



166 CLINICAL VARIETIES OF TUBERCULOSIS. 

what has been already said, is often extremely difficult. The pos- 
sible relation of the case to others of typhoid fever should be in- 
quired into. The observation of choroid tubercle or the discovery 
of tubercle bacilli in the blood where they have been demonstrated 
in a few instances, will, of course, set the question at rest. The ap- 
plic^ation of the serum test for typhoid fever will aiFord valuable 
negative evidence. Less well-defined criteria are the absence of the 
characteristic rash, the irregular character of the temperature curve, 
and the nature of the stools if diarrhoea exist. It is often necessary 
to give a very guarded diagnosis at first, and it should be borne in 
mind that tuberculosis may occur as a complication or sequel of 
typhoid fever. Some cases of acute or subacute enteritis may re- 
semble acute tuberculosis very closely. In such cases the child 
looks very ill, and may be delirious ; it loses flesh rapidly, refuses 
food, and is very thirsty. The tongue, furred at first, becomes red 
and irritable. The abdomen is shallow, not very tender, and there 
may be no diarrhoea, or the stools, though frequent, are scanty. 
There is some irregular pyrexia, rising to a maximum of 102°-104° 
F. A guarded opinion must often be given at first, though the his- 
tory of sudden onset, which is the rule in enteritis, the absence as a 
rule of bronchitis, of enlargement of the spleen, of irregularity of 
the pulse, and, it may be, the occurrence of other similar cases in 
the same house or neighborhood may render it possible to make a 
provisional diagnosis, even on the first occasion on which the patient 
is seen. 

The prognosis is hopeless when the diagnosis is certain, and treat- 
ment produces no effect upon the course of the disease. The most 
that can be aimed at is to relieve symptoms and promote euthanasia. 

Chronic General Tuberculosis occurs in infancy, and probably 
never after the second year. There is usually a history of an ante- 
cedent attack of bronchitis or broncho-pneumonia, or of measles or 
whooping-cough. The patient has apparently recovered from the 
acute attack, but does not regain his former health. In other in- 
stances the onset is insidious without obvious determining cause. In 
either case the characteristic symptoms are progressive emaciation, 
though the appetite is retained and is, indeed, commonly ravenous. 
In spite of the eagerness with which it takes food the infant is ex- 
tremely thin, the skin, which hangs in loose folds on the limbs, is 
inelastic, and when pinched up returns only slowly to its original 
position. The face is pinched, but in young infants the sucking i: 
pads are usually prominent, the eyes are sunken, and the expression 
is tired, peevish, and anxious. The patient often has long eyelashes 
and an unusual amount of hair over the back and other parts. The 
liver and spleen are both enlarged, and there are small shotty glands 
in the axillae and groins. The temperature is not raised, or only to 



CHRONIC GESERAL TUBERCULOSIS. 167 

a slight degree and at irregular intervals. Xot infrequently it is 
subnormal. There may be no physical signs of any pulmonary dis- 
order, though in some cases there is some evidence of bronchitis, or 
of consolidation at the apex, hilum, or base. A dry cough is the 
rule, and an intercurrent attack of bronchitis may cause some tem- 
porary elevation of temperature. Diarrhiea and vomiting may be 
absent altogether, or there may be some slight increase in the fre- 
quency of the stools and some alteration in their character owing to 
the passage of an increased quantity of mucus. Some of the in- 
fants who pass into this state are found to be suffering from otorrhcea, 
and there is much reason to believe that this, in many cases, de- 
pends u|X)n tuberculous disease of the middle ear. Tuberculous 
meningitis may ensue upon tliis otitis, or may come on without any 
such antecedent. Frequently, however, no complication develops, 
but the patient, in spite of the most careful feeding and nursing, 
grows gradually thinner and weaker, and is presently found dead in 
its cradle or even in its nurse's arms. In other cases death is deter- 
mined rapidly by tuberculous meningitis, or broncho-pneumonia, or 
adenitis of the tracheo-bronchial glands. After death tuberculous 
disease may he found very widely distrilnited in the lungs, glands, 
spleen, liver, meninges, and more rarely in the kidneys, intestines, 
and thymus gland. 

The diagnosis must generally rest largely upon the exclusion of 
other causes <»f progressive emaciation, such as insufficient food, chronic 
enteritis, relapsing broncho-pneumonia, and the condition of feeble- 
ness and imperfect powers of assimilation observed sometimes in 
children born before term. The cachexia of congenital syphilis may 
occasionally cause some hesitation, but the emaciation is not so ex- 
treme, polyadenitis (axillse and groins) is not present, and the skin, 
even if it presents no characteristic or suspicious lesions, has a sub- 
icteric tinge. The existence of chronic ear disease will tend to con- 
firm the diagnosis of tuberculosis. 

The prognosis is unfavorable, although cases in which the diagnosis 
has been made occasionally recover, at least temporarily. If the 
hygienic surroundings of the patient can be made satisfactory, and 
if treatment leads to a gain in weight, some hope may be entertained 
of eventual recovery. 

Treatment must be directed U* maintaining nutrition, l)y careful 
dieting, by keeping the child out of doors for many hours a day, l)y 
free ventilation of the nurser)', and by the administration of cod-liver 
oil, malt extract, or syrup of the phosphate of iron. The cases which 
recover, however, are usually those which are able to digest cod- 
liver oil. 

Tuberculosis of bones and joints is the commonest localization of 
the di-ease in early childhfKxl and lias been estimated (Brandenburg) 



108 CLINICAL VARIETIES OF TUBERCULOSIS. 

to constitute 43 per cent, of all examples of tuberculous disease met 
with under four years of age. The consideration of this division of 
the subject falls to the surgeon ; but it may be here remarked that 
surgical interference is in some cases, happily comparatively rare, 
followed by the outbreak of general tuberculosis or tuberculous men- 
ingitis. 

Lymphatic Glands. — Chronic tuberculous disease of the cervical 
glands is one of the commonest forms of struma, as is indeed shown 
by the term " The King's Evil " applied to it when the royal touch 
was believed to be a sovereign cure for scrofula. In the majority 
of cases the specific infection is, no doubt, secondary to a simple 
adenitis, due to disease of the naso-pharynx or tonsils, or of the scalp 
(impetigo, eczema, pediculi), or of the teeth, but in others it is pri- 
mary. Whether preceded by simple adenitis or not, the tuberculous 
infection is in the majority of cases derived from the tonsils and naso- 
pharynx. Tuberculous lesions of these parts are not a necessary 
antecedent, though chronic tonsillitis and adenoid vegetations, if not, 
as Dieulafoy supposes,^ actually due to tuberculous infection, un- 
doubtedly favor infection in two Avays : (1) By the retention of the 
tubercle bacilli in the follicles of the tonsils or among the vegetations ; 
and (2) by diminishing in these parts the activity of the phagocy- 
tosis upon which the destruction of bacilli depends. The enlarge- 
ment of the glands is indolent, and retrogression and recovery the 
rule ; but an attack of an acute infectious disease, such as measles, 
or of acute tonsillitis, or a local injury, or any cause producing de- 
terioration of the general health may determine suppuration. A fur- 
ther risk is the extension of the tuberculous disease to the tracheo- 
bronchial glands, and thence to the lungs.^ The enlargement of the 
glands may be enormous, obliterating the normal outlines of the neck 
and producing that resemblance to the thick neck of the pig which 
is said to be the origin of the term scrofula.^ The glands primarily 
involved in carious teeth are those immediately beneath the jaw. 
Frequently the axillary glands are inv^olved along with the cervical, and 
a continuous chain exists under the clavicle and the pectoral muscle. 

The medical treatment of this condition resolves itself practically 

^Bdl deVAcad. de Med., 1895, Av. 30. 

2 Eustace Smith [Lancet, 1895, vol. i., p. 1299) has made an ingenious suggestion 
as to another mechanism which may favor tuberculous infection of the lungs in cases 
of adenoid vegetation. He argues thus: — "Inspiration is inhibited by stimuli pass- 
ing upwards through the superior laryngeal and the glosso-pharyngeal nerves ; irri- 
tation continually applied to the periphery of these nerves must greatly restrict the 
admission of air to the lungs ; the parts of the lungs least expanded will be those be- 
neath the most flexible parts of the chest wall — the infra-mammary and supra-clav- 
icular spaces : since the lungs cannot work fully, they cannot develop fully, and 'small 
lungs are always vulnerable lungs,' therefore the liability to pulmonary phthisis is 
increased." 

3 Lat. scrofula, a little pig, diminutive of scrofa, a breeding sow, literally a digger, 
from the habit of swine. (Skeat. ) 



LYMPHATIC GLANDS. 169 

into the treatment of those local conditions which produce adenitis of 
the cervical irlands. The fact that lesions of tlie naso-pharvnx, of 
the scalp, and of the teeth arc capable of pnHlucincr a chronic adenitis 
■which is very liable to become tuberculous, lends a sj>ecial inipor- 
ance to the early and persevering treatment of such affections. 

The tracheo-bronchial glands are the seat of tubcrcuh>us disease 
very frequently, and this condition is of great importance in n^hition 
to both general anil pulmonary tuberculosis. 

The trachea near its bifurcation and the large bronchi are in inti- 
mate relation with a large number of lympliatic glands. Tliey may 
b3 divided into tliree groups : (1) The tracheal, on either side of the 
windpipe. (2) The tracheo-bronchial, which lie in the angle of 
bifurc-itiou of the trachea and along the main bronchi ; their most 
important relations are, in addition to the bronchi above, with the 
pulmonary veins below, and with the avsophagus, aorta, and posterior 
border of the lung behind. (3) The peri-bronchial, which are in 
contact with the main bronchi, their first subdivisions at the hilum 
of the lung, and with the bronchi as far as the fourth subdivision. 
These groups form one system massed about the end of the trachea, 
which corresponds with the third dorsal vertebra behind, and the 
junction of the manubrium with the gladiolus in front. The deep 
lymphatics of the neck, which lie both in front of and behind the 
carotid sheath, are continuous with those about the l)ifurcation of the 
trachea, and both with the subclavicular glands. In four out of five 
cases of tuberculosis in children the bronchial glands are affecteil, 
and in many cases it appears almost certain that this adenitis was 
the primary lesion (Fig. 12). These glands receive all the pulmonary 
lymphatics, and no doubt, in many cases, they are infected l\v 
tubercle bacilli, which have reached the lungs with the inspired air 
and have been carried back to the lymphatic glands. It has already 
been })ointed out, in the remarks on etiology, that the bronchial glands 
may also l>ecome infected by gradual extension, in continuity either 
downwanls from tlie cervical glands or upwards from the mesenteric, 
the infection being derived from food. 

The affectefl glands become enlarged. In many cases, no doubt, 
esi>ecia]ly after whooping-cough or measles, the enlargement is due, 
in the first place, to a simj>le adenitis which precedes and paves tlie 
way for the occurrence of tuberculous infection. The swollen glands 
are firm, and on section show a surface more or less pigmented ac- 
cording to the age and place of residence of the patient, but on the 
whole are semitransparent with one or more caseous patches. The 
caseous area^ may be large, or some may have broken down into 
cavities oontaining a puriform fluid. In other cases of old standing, 
there miy be more or less calcification, whicii may even be so exten- 
sive that the whole gland is transformed into a shrunken and calcare- 



170 



CLINICAL VARIETIES OF TUBERCULOSIS. 



oils mass. An enlarged gland may become adherent to surrounding 
structures, and if a cavity has formed in the gland it may empty its 
puriform contents into one of the adjacent hollow organs. Kupture into 
the pulmonary artery causes sudden, profuse, and fatal hsemorrhage ; 
rupture into a bronchus leads to the formation of a cavity, the walls 
of which may consist in part of the altered lung substance, and in 
part of the remains of the gland ; rupture into the pleura may lead 
eventually to pneumothorax ; rupture may also occur into the peri- 



FiG. 12. 




Section of the lung made through a mass at the root consisting of enlarged cheesy glands, 
blood-vessels, and bronchi. The section has passed also through cheesy masses within the lung. 
The infection in these situations is evidently of some standing. The cut surface of the lung shows, 
also, numerous recent tubercles, and similar tubercles are seen also on the dark surface of the con- 
gested pleura. One-quarter natural size. (After Northrup.) 

cardium, into the oesophagus, or into the trachea. The accident last 
named may cause sudden death, owing to impaction of a portion of 
the caseous gland in the trachea (Fig. 13). This has occurred in an 
infant of one year/ but most of the recorded cases have been from 
three to twelve years. A smaller mass carried into a bronchus may 
cause acute localized bronchiectasis.^ It is probable that in some 

'K. W. Parker, Clin. Soc. Trans., Vol. xxiv., p. 6. 
2 Shaw, Trans. Path. Soc, xxxviii., p, 90. 



171 



LYMPHATIC GLASDS. 



cases the entrance of caseous material from the glands into the trachea 
or bronchi has, by its aspiration into the bronchioles, determined the 
outbreak of a widespread and acute tuberculous broncho-pneumonia. 
Geill, in the series of cases already referred to, met with perforation 
of a bmnchus by a softening gland four times. Xorthrup's ' re- 
searches certainly support the view that in infancy and early child- 
hood tuberculosis of the lungs is, in the great majority of cases, either 
a part of a more or less widely disseminated atiection, or is secondary 
to tuberculosis of the bronchial glands. The tuberculosis extends to 
the luuiTS usuallv bv continuitv : the oland becomes adherent to the 



Fig. 13. 




Th«r trachea and main bronchi from a case in which'death was due to .sudden dyspuaa produced 
y the rupture and dislocation of a caseous bronchial gland into the trachea. The spot at which 
lie bronchial gland r)onetrated the trachea is shown, and at A the gland detached, ;>'MM;K;r/^;n, 
with its petlicle, consisting of thickened capsule by which it was tethered so that its removal was 
impoysibie, even after tracheotomy (Mr. K. W. Parker's case). Such a rupture is not very uncom- 
mon, though the mode of death is rare. 

lung, and the tuberculous process overflows, as it were, from the 
glandular to the pulmonary ti.ssue. The tendency to generalization 
from the glands directly appears to be small ; the infection, as a rule, 
passes first to the lungs, and becomes generalized from thence by 
way of the blorxl (Fig. 12). 

The physical signs of the enlargement of the trachco-l>ronciiial 
glands are diminished resonance in the interscapular region, especi- 
ally on the right side, and blowing or harsh resj)iration in the same 
regif»n. The symptoms are: (V) paroxysmal cough resembling that 
of whwiping-eough, and ending often in vomiting, but without well- 

>JV«c YorkMeiUrfdJour., 1891, Vol. liii., p. 201. 



172 CLIJSICAL VARIETIES OF TUBERCULOSIS. 

marked crowing inspiration ; (2) dyspnoea on exertion with slight 
cyanosis, and attacks resembling asthma. Simple adenitis of this 
group of lymphatic glands occurs most often as a sequel of measles 
or whooping-cough, and the symptoms, varying in severity from 
time to time, may persist for two or three months. Chronic adenitis 
of the tracheo-bronchial glands in children is, in most cases, tuber- 
culous, and other forms of mediastinal tumor are exceedingly uncom- 
mon in early life. 

The diagnosis is extremely uncertain ; in many cases there are no 
symptoms, or they are ambiguous, and, with the physical signs, rather 
suggestive of broncho-pneumonia. Dyspnoea, produced by pressure 
on the trachea, may simulate bronchitis, with which it is often asso- 
ciated. The paroxysmal cough is not usually attended by inspiratory 
stridor and true whooping, but the resemblance of the symptoms to 
those of whooping-cough is so close that Gu^neau de Mussy advanced 
the opinion that whooping-cough was due to a specific inflammation 
of the tracheo-bronchial glands. The history of contagion, and oi 
the mode of onset of whooping-cough by a stage of fever antecedent 
to the whooping stage, as well as the characters of the cough, will, 
in a well-marked case, serve to distinguish the two conditions. In 
some cases, again, the paroxysms of dyspnoea suggest those of asthma, 
which is, however, a rare disease in early childhood. When there is 
hoarseness as well as dyspnoea the question of tracheotomy may arise, 
and since sudden dyspnoea in a young child may be due to a prolapse 
of a caseous gland, the operation ought to be performed, as it seems 
possible that under favorable circumstances the debris of the gland 
might be coughed up. 

The prognosis of tracheo-bronchial adenitis, when the glands have 
become sufficiently enlarged to permit a diagnosis to be made, is 
grave, though there is no doubt that in less severe cases the tuber- 
culous process frequently undergoes regression. 



CHAPTER XII. 
TUBERCULOSIS OF THK ARDOMIXAL ORGANS. 

Tuberculosis of the Mesenteric Glands — Tuberculosis of the Peritoneum : Acute. 
Chronic — Stomach — Spleen — Liver. 

TruKRcrLOUs, or " scrofulous," disease of the mesenteric glands 
was formerly supposed to occur very frequently in infancy and early 
childhood as an independent disease, and to be a common cause of 
marasmus. The popular term "consumptive bowels" includes 
tul)erculous enteritis, j>eritonitis, and adenitis, but, in the majority of 
'^ases, the disease is a non-tuberculous chronic enteritis or entero- 

•litis. The mesenteric glands may become infected, either second- 
arily from tuberculous lesions of the intestines or peritoneum, or in 
the manner already described by the direct transmission of the virus 

•ntained in the food. The glands become enlarged in the course of 
typhoid fever, and in some cases of scarlet fever and measles. This 
adenitis quickly subsides, as a rule, l)ut, as in the case of the tracheo- 
bronchial glands, it may pave the way for tuberculous infection, or 
light up a latent infection. 

Tul)erculosis of the mesenteric glands, unless and until the glands 
attain a large size, produces no characteristic symptoms ; wasting, 
alternate constipation and diarrhrea, and tympanites can only reason- 
alily be attributed to tuberculous disease of the mesenteric glands if 
the glands can be felt through the abdominal wall. This, even when 
the glands attain a large size, and form by agglomeration a tumor, 
which may be as big as a first, is not always possible, owing to the 
gaseous distension of the intestines.* The pressure of such a mass 
upon the vena cava may cause oedema of the lower extremities. It 
seems doubtful, however, whether so considerable an affection of 
these glands ever exists without tuberculous disease of the intestines 
or peritoneum, or Ixjth. The main im}X)rtance of tuberculosis of the 
mesenteric glands is that the tul)ercle bacilli derived from the food 
find there a nidus in which they multiply, and from which they may 
l)e disseminated especially through the tracheo-bronchial glands to 
the lungs. 

'Henoch, for example ( VorUfunffen H. Kirulcrkrank., fitc Auf., 1892, 8. h'A), men- 
tions a ca.«e in which a tumor of this nature, larger than a child's hea<l, could not be 
f>erceived daring life. 

173 



174 TUBERCULOSIS OF THE ABDOMINAL ORGANS, 

[Worcester has seen cases of tuberculosis of the mesenteric glands, 
which have been regarded and treated as " chlorosis/' and the true 
nature of which he discovered only on subjecting the patient to the 
tuberculin test (vide infra). He earnestly advocates this test in all 
cases of suspected tuberculosis.] 

Tuberculosis of the Peritoneum. — The peritoneum may become 
infected as part of a general tuberculosis, the infection reaching the 
serous membrane by the blood stream. More often it is carried by 
the lymphatics, either from the pleura, or from the genito-urinary 
organs, both rare events in children, or from the intestines. In the 
last case, which is the common mode of infection, there may or may 
not be tuberculous disease of the intestines.^ In many, probably in 
the majority of cases, the intestinal mucous membrane shows no 
lesion, or evidence only of catarrh, which is often secondary. Re- 
peated catarrhal attacks are, however, among the predisposing causes 
of tubercle of the peritoneum, since they weaken the resisting power 
of the intestinal epithelium. In these cases the tuberculosis may be 
— at first, at least — limited to the peritoneum. 

Three types may be distinguished : (1) Miliary ; (2) caseating ; 
(3) fibrous. 

Acute miliary tuberculosis of the peritoneum is generally a part of 
a general tuberculosis, or is associated with tuberculosis of the pleura. 
The surface of the peritoneum is studded with small gray tubercles, 
closely set. The serous membrane itself is usually inflamed, its sur- 
face has lost its polish, and soft adhesions have formed between ad- 
jacent organs and coils of intestine, but the cavity of the peritoneum 
is not obliterated ; on the contrary, it contains usually a large 
quantity of clear yellow or greenish fluid. The mesenteric glands 
are slightly enlarged, but soft and semi-transparent. At a later 
stage the serous surface is covered by layers of fibrinous exudation, 
which can be detached easily, bringing the tubercles with them. 

The symptoms of this form are very apt to be misinterpreted. On 
the one hand, if the miliary tuberculosis of the peritoneum be a part 
of a general tuberculosis, the symptoms present a very great resem- 
blance to typhoid fever. Owing to the fact that there is usually 
much tympanites, the presence of fluid is masked, while abdominal 
tenderness (which is often neither general nor very marked), the 
fever, and depression present a close resemblance to the conditions 
produced by typhoid fever. On the other hand, when the tubercle 
is confined mainly or entirely to the peritoneum the condition is apt 
to be taken for acute peritonitis. The latter mistake is almost im- 
possible to be avoided, since the eruption of tubercles on the serous 

^ The cases to which the terms Tabes Mesenterica and Tabes Mesaraica were form- 
erly applied were, as a rule, instances of chronic tuberculosis of the peritoneum or 
mesenteric glands. 



TUBERCULOSIS OF THE PERITONEUM. 175 

surface determines an acute inflammation of the membrane, and the 
symptoms — pain, tympanitic distension, and ascites — are, in fact, 
due, in large part, at least, to the peritonitis, and not to the tubercle 
by which it has been produced. The temperature rises steadily, and 
does not show the regular remissions of typhoid fever. The pulse 
is rapid and thready. Evidence may frequently be obtained of })leu- 
risy with effusion. The patient is obviously very ill, lies in bed on 
the back, with legs drawn up. Food is refused, vomiting is fre- 
quent, and the vomited matters become, after a time, bilious. 

The prognosis is, of course, bad, but on the whole less unfavorable 
than in simple peritonitis of equal intensity. The majority of 
patients succumb within two or three weeks or a month ; but re- 
covery may take place, the peritonitis subsiding and the tubercles 
eventually undergoing a fibrous change. 

Chronic tuberculosis of the peritoneum is usually of the caseous 
type. Numerous tuberculous masses of varying size are present in 
the peritoneum and in the false membranes by which it is covered. 
Adhesions form in many directions, and irregular cavities, containing 
a puriform fluid, sometimes stained red or brown by recent or old 
haemorrhage, are produced. The larger caseous masses tend in time 
to soften and in their immediate neighborhood may be found recent 
crops of small gray miliary tubercle. In fatal cases tubercle is 
found also in other organs, especially the pleura. Cicatricial changes 
are associated with the caseation in all the more chronic cases, but in 
some instances, especially those in which the tubercle is more deeply 
seated in the wall of the intestine, fibrosis is marked from, perhaps, 
the earliest stage. In such cases the serous membrane and its over- 
lying false membranes form thick masses, layers, and bands, with 
caseating tubercles in their substance. The coils of intestine may be 
everywhere adherent, and separated only with difficulty. Perforation 
of the intestine may take place either into an adjacent coil or into a 
space among the coils, which is thus converted into an abscess cavity. 
In other cases the intestines, matted together by adhesions, but with- 
out any extensive adhesions to the parietal peritoneum, are, in the 
process of fibrous contraction, drawn back towards the vertebral 
column, forming a mass no larger than the fist. The mesenteric 
glands are enlarged and caseous. They may break down, and even- 
tually discharge through the peritoneum ; or they may, owing to 
fibrosis, become shrivelled, a process which is often accompanied by 
a cretaceous change. 

The symptoms of chronic tuberculosis of the peritoneum ])resent 
great variety. As a rule, the onset is very insidious, and advice is 
sought because the belly has l^een noticed to be growing large while 
the child has grown thin and antemic, and has lost appetite. The 
alxlomen is dome-shaped, with the umbilicus, which is often everted, 



176 TUBERCULOSIS OF THE ABDOMINAL ORGANS. 

sometimes flattened, at the apex. Even in the early stage the con- 
trast between the prominent distended abdomen and the pinched face 
and wasted limbs is often very characteristic. The abdomen is usu- 
ally resonant throughout, fluid, if present, being masked by the 
gaseous distension of the intestines. Tenderness may or may not 
exist, but is seldom a prominent symptom. Attacks of colicky pain 
occur in many cases, and sometimes this is the first symptom noticed. 
During the course of the case the aspect of the abdomen may vary 
very much in relation with variations in the physical conditions. 
With a diminution in the amount of gaseous distension it may be 
possible to feel the irregular thickening of the omentum, and of the 
peritoneal surface of the intestines, and the enlarged mesenteric 
glands. These thickenings are, however, less easy to perceive than 
might be supposed. The liver may be enlarged, and the spleen is 
always affected, though it may not always be possible to detect any 
swelling during life. Great variations are to be met with in the 
quantity of fluid effused. In some cases the effusion is copious and is 
easy to be recognized ; in others it may be impossible throughout the 
case to be certain of its presence. In others, again, it may be detected 
at one time, its absorption may be observed, and later a fresh effusion 
may be discovered. In the absence of other well-marked signs of 
tuberculosis this disappearance and reappearance of peritoneal effusion 
is a valuable sign, and should raise a suspicion of tuberculosis. Ex- 
tensive effusion, free in the cavity, may be caused by intercurrent 
peritonitis, or by a fresh eruption of miliary tubercle on the peri- 
toneal surface, but is, in some cases, due to cirrhotic or interstitial 
tuberculous disease of the liver. Localized collections of fluid, so- 
called encysted peritonitis, are difficult to recognize, and commonly 
it is not possible to do more than surmise their existence. They are 
usually purulent, and are often associated with perforation of the in- 
testine. In a minority of cases the fluid burrows towards the surface 
and eventually finds exit by the umbilicus ; or points, generally in 
the umbilical but occasionally in one or other iliac region. Tuber- 
culous ulceration of the intestine is a common complication of tuber- 
culous peritonitis, at least in its later stage, and the perforation may 
take place from within. Frequently this accident is unrecognized 
during life, the fpecal effusion and the resulting peritonitis being 
limited by the adhesions between the coils of intestine. Perforation 
may also occur from the peritoneum into the intestine, leading, per- 
haps, to the emptying of a localized collection of fluid into the gut. 
In other instances the ulceration into the intestine establishes a fistula 
between two coils. In either case the invasion of the intestinal 
mucous membrane causes severe diarrhoea, by which the patient's 
strength may be rapidly exhausted. In the later stages of a chronic case 
great recession of the belly may attend retraction of the intestines 



!l 



TUBERCULOSIS OF THE PERITOSEVM. 177 

to\vard> tlie vertebral eoluinn. Through the wasted alHloiniiial walls 
the airglutinateJ intestines may then be felt as an irregular tumor of 
doughy consistence, in which are embedded hard plaques or bands. 
It is not uncommon to find the ujiper part of the abdomen thus re- 
tracted while the liy})ogastrium is distended and contains fluid. The 
fever attending tuberculosis of the peritoneum is irregular ; for weeks 
together no elevation of temperature may be noted, and then with 
some aggravation of the local symptoms, due perhaps to a fresh out- 
break of tubercles or to localized suppuration, pyrexia may set in and 
continue for a long period. AVith caseation and suppuration the 
fever tends towards the hectic type. The patient grows weaker, and 
more emaciated ; the skin assumes an earthy tint ; the extreme ema- 
ciation (»f the lower limbs may be masked by (xnlema, and the skin is 
rough and dry except when, with a sudden fall of temperature after 
a hectic rise, it is for a short time drenched with sweat. The pulse 
is soft, small and frequent ; appetite is lost completely. Vomiting, 
determineil by the ingestion of even small quantities of liquid food, 
is frequent, and profuse diarrheal often ensues to still further under- 
' mine the strength. The patient is bedridden ; and sores on the 
I sacrum, hips, shoulders, and elbows can hardly be prevented by the 
most careful nursing. 

Prognosis. — The general tendency of chronic tuberculous peritonitis 
is towards ileath l>v exhaustion, owing to the interference with nutri- 
tion, or by involvement of other organs, especially the lungs. The 
patient is also liable to internal strangulation by bands, or to obstruction 
by compression or kinking of the gut. In some cases, which present 
all the early symptoms of tuberculosis, the abdominal distension de- 
creases, and finally disappears, the nutrition improves, and the child 
'makes, apparently, a complete recovery. When the later stage of 
jgeneral adhesion of the intestine, with retraction, and the formation 
of local purulent collections, has been reached, the prognosis is very bad, 
though evacuation of the pus either spontaneously or by operation, is 
jfollowed occasionally by recovery if continuance of the suppuration 
can be avoided. The chance of recovery depends to a large extent 
lupon whether the intestinal mucous membrane has escaped ; if it has, 
'there is some hope, if suppurative fever be absent also, that nutrition 
may be maintained. 

Medical Treatment of peritoneal tuberculosis, whether acute or 
^chronic, cannot be more than palliative, and must follow the same 
neral lines as in simple acute or chronic peritonitis (7. v.). The 
estion of the desirability of performing laparotomy, whether pre- 
lecl by paracentesis or not, is the more pressing since there is evi- 
ce that the withdrawal of fluid effused into the cavity of a serous 
mbrane affected by tuberculosis favors the arrest and retrogression 
f the tuberculous process. The number of ca.ses mostly, however, 
12 

ll 
V 

I 



178 TUBERCULOSIS OF THE ABDOMINAL ORGANS. 

in women, in which this operation has been performed for tubercu- 
lons peritonitis is now considerable, and apparent recovery has en- 
sned in about a quarter. The results in children have not been so 
good, but the number of reported cases under ten years is very small. 
The best results are likely to be obtained in cases in which there is 
a good deal of ascites, and if the operation is undertaken early, be- 
fore adhesions have formed. Puncture is often followed by local ad- 
hesive peritonitis, and if the tuberculous nature of the peritonitis can 
be established it seems probable that laparotomy would give better 
results if performed at once, or, at most, after a single paracentesis. 
Henoch, who recommends frequent puncture and is not disposed, as 
a rule, rashly to resort to surgical methods, yet expresses the opinion 
that, in all cases in which, after treatment for four weeks and several 
punctures, no improvement has taken place, an exploratory laparot- 
omy should be performed. When there is evidence of localized sup- 
puration there will be less hesitation in adopting surgical treatment. 
In chronic tuberculosis of the peritoneum every effort should be 
made to maintain nutrition. With this object in view the patient 
should have the enjoyment of pure air and sunlight for as many 
hours of the day as possible ; while the avoidance of exertion is de- 
sirable, confinement to bed or to the house has a most injurious eifect 
on the a:eneral health. The abdomen should be covered with a 
flannel bandage, and, when warmly clad, the patient can be out of 
doors in a reclining carriage or on a couch for the greater part of 
fine days even during an English winter. The advantages of a 
warmer winter climate are, however, evident. The diet should be 
as ample as can be digested, and of the kind recommended in in- 
testinal tuberculosis, with wdiich peritoneal tuberculosis is, sooner or 
later, so commonly complicated. 

Tuberculosis of the intestines is less common in children than 
in adults. It may be primary, the infection being derived from the 
food, or secondary to, as a rule, pulmonary tuberculosis, the bacilli 
being carried to the intestines by the sputum which is swallowed. 
When tuberculosis becomes generalized, the intestines may be in- 
volved along with other organs. 

The conditions which exist in the intestines are not favorable to 
the growth of the tubercle bacillus. Prolonged contact with the 
mucous membrane, or some injury to its epithelium appear to be 
conditions necessary to the occurrence of infection. The first con- 
dition is fulfilled in the lower part of the ileum, immediately above the 
ileo-cjecal valve, and tuberculous ulceration is most often found in 
this situation, the second, by antecedent enteritis. The infection 
may become established first in the lymphatics which accompany 
the blood-vessels in the walls of the intestine, in Peyer's patches, or 
in the solitary glands. The effect is to produce granulomatous^ 



TUBERCULOSIS OF THE lyTESTIXES. 179 

tliiokening:s which are in the tirst ease anmihir, in the seeoiul lonoi- 
tiulinal, and in the third small, ronnd, and scattered. The urannlo- 
matons tissue underiioes caseous degeneration, and breaks dt)wn, 
leaving ulcers which have, at Hrst, one or other of the forms indi- 
cated. Extension may take place by the formation of fresh granu- 
lations about the ulcers. In children the parts most often affected 
are IVyer's patches, and the typical annular ulcers are therefore less 
often seen in them. The ulcers have a thick irregular cd^^o and a 
coarsely granular surface. Their depth varies in proportion to the 
amount of attendant thickening and tuberculous infdtration. The 
muscular coat may be involved, and eventually the continuity of the 
intestinal wall maybe maintained only by the thickened peritoneum. 
Actual perforation is a rare event, especially in children. Cicatriza- 
tion mav occur and mav entail extreme constriction of the ffut. The 
large intestine is not often affected, but it is not uncommonly the 
site of a more or less acute and extensive catarrhal intlammation, 
with shallow ulceration, the speciiic nature of which is doubtful. 
The symptoms of tuberculous ulceration of the intestine are far 
I from characteristic, and its existence during life is more often sus- 
' pected than proved. Whether the intestinal disease be ])nmary or 
I secondary, the tirst symptom to attract attention to its existence 
i is usually diarrha?a. The motions at first are not very frequent, 
i perhaps night and morning a soft, light-colored stool is ])asscd. 
i Gradually the motions become more numerous and fluid, and darker 
' in color, until finally they are very dark brown, or even tarry, 
, owing to bleeding from the ulcers. In its later stages the diarrhoea 
I is very profuse, watery, and can be retained with difficulty. The 
( odor of the stools is horribly offensive. The bacillus has been 
found in the stools. Thealxlomen is not constantly either distended 
j or retracted. Tenderness may be elicited by firm pressure, or by 
I gradually making deep pressure, and then removing the hand sud- 
* denlv. Sometimes there is much colickv i)ain, and in some cases 
: alxlominal pain of a neuralgic character is an early symptom. It is 
\ not uncommon to be able to elicit a history of an attack of acute 
j diarrhrea with colic some weeks or months before the onset of the 
I persistent diarrhrea. This early diarrhrea has been attributed, with 
i much probability, to the irritation produced by the first formation 
i of tubercle ; the final diarrlnea being due to the consccjuent ulcer- 
i ation. Eraiiciation and loss of strength are rapid and progressive 
< unless the diarrhrea can be controlled by treatment. The fever 
I produced by tuberculous ulceration of the intestines is of the hectic 
! ty|)e ; usually it is not high, ami when the disease occurs as a com- 
i plication of pulmonary tuberculosis it may not ])rodii(r any recog- 
nizable effect on tiie temj)erature curve. 
/ The diagnosis miLst depend to a great extent uj>on the rec<>gnition 



180 TUBERCULOSIS OF THE ABDOMINAL ORGANS. 

of tuberculosis elsewhere. The existence of tuberculous enteritis 
may be assumed with tolerable certainty when diarrhoea^ having the 
characters mentioned, sets in in the course of tuberculosis of the 
lungs or peritoneum. When, however, the disease of the intestines 
is primary, the diagnosis cannot be made with confidence. 

The prophylaxis of tuberculosis of the intestines, owing to the seri- 
ous and intractable nature of the malady, is of great importance ; the 
liability of infection from the food, to which children fed mainly on 
milk are especially obnoxious, and the means by which it may be 
avoided, have already been mentioned. Infection by the sputum 
from tuberculous lungs should be guarded against by teaching the 
patient to expectorate what it coughs up into the pharynx, a difficult 
matter in young children. The propriety of the early and systema- 
tic treatment of intestinal catarrh will be obvious, since the liability 
to tuberculous infection is increased by the epithelial lesions which it 
produces. The child should wear a flannel bandage or cholera belt 
over the belly, and the thighs and legs should be warmly clad. The 
treatment of the disease when thoroughly established must be mainly 
palliative, and the remedies at our command are the same as those 
used in chronic enteritis. 

Bismuth is the most valuable remedy. It may be combined in a 
mixture with tincture of opium or compound tincture of camphor, 
and should be given in frequent doses. When the pain is severe, 
morphine may be administered by hypodermic injection and hot 
fomentations or poultices applied to the belly ; when the pain is ac- 
companied by intractable diarrhoea small enemas of starch and 
opium (5j to Sxj of starch freshly made, with tincture of opium TTL v 
to XV, according to the age and general state) are useful to relieve 
both conditions. When tenesmus or the presence of much mucus in 
the stools points to affection of the large bowel, large injections of 
solution of nitrate of silver (1 per cent.) or sulphate of zinc have 
been recommended. The patient should lie on the left side, and be 
encouraged to retain the solution — Avhich must be injected very 
slowly — as long as possible. Hayem has had good results from the 
administration of lactic acid by the mouth (TTl iij every three hours, 
increased gradually to thrice that quantity). Debove states that talc 
finely powdered, and given stirred up in milk, to the extent of an 
ounce or more during the day, sometimes has the effect of arresting 
the diarrhcea. If it subside, cod-liver oil in mixture, guarded by a 
small dose of opium, is often well borne. The diet should be simple 
and nourishing. Milk, sterilized unless it can be obtained from an 
irreproachable source, is the best. It should contain all the cream, 
or it may be diluted with an equal quantity of lime-water or whey, 
and the amount of cream made up, if it is found that the patient can 
digest it. Koumiss and Kephyr and aerated milk are valuable sub- 



I 



TUBERCULOSIS OF THE STOMACH. ISl 

stitiites when milk is not well borne. Beyond milk the diet shonld 
consist mainly of meat in any form in wliich it can be best taken. 
Fats, snch as butter and fat bacon, should be taken as freely as pos- 
sible, but, they are not well borne wlien the temperature is elevated 
or diarrhaw severe. Vegetables, especially green vegetables and 
leorumens, should be forbidden ; thev ar.^ not easilv diorested and tend 
to produce flatulence, wliich is a source of pain and danger. Potatoes, 
bread, and porridge, and other similar foods should be given with 
caution ; and bread in small quantities, toasted, or, in its place, 
well-made friable biscuits. Sound fresh fruit, if freed from indiges- 
tible parts, can often be taken with advantage and without discom- 
fort. 

Tuberculosis of the Stomach has been observed in chihlren, but 
is ver}' rare. Tuberculous granulations form in the mucous mem- 
brane, caseate, and break down, forming round ulcers which bleed 
easily. The symptoms are pain, vomiting, and hfematcmesis, whicli 
may be very copious, and cause death rapidly. The intestines, and 
in some cases the peritoneum also, present tuberculous lesions. 

It is convenient to add here that tuberculous ulcerations of 
the tongue and of the palate may occur in childhood, but they are 
extremely rare. On the tungue the ulcer is deep, with sharp edges, 
a vellow and slouorhv base, and more or less surroundiufr induration. 
The prognosis is extremely bad, general or ])ulmonary infection being 
the sequel in most cases. Tlie treatment which offers most hope of 
success is the excision of the ulcer, or scraping, followed by applica- 
ti« tiis of chloride of zinc. 

rhe spleen in acute tuberculosis is invariably the seat of tubercle, 

and in a very large proportion of cases of chronic tuberculous disease 

of the lungs, peritoneum, intestines, and miMiinges, it contains tuber- 

I cles, which, however, miy not be perceptible to the naked eye. 

. Acute or extensive tuberculosis of the spleen is attended by enlarge- 

I ment of the organ, but it miy be affected without the enlargement 

\ bain^ suffieientlv extensive to be reco^cnized durinfr life. 

; In acute miliary tuberculosis the liver seldom escapes in children. 

j In peritoneal tuberculosis the infection may penetrate the liver from 

' the surface, while in tuberculous ulceration of the intestine the infec- 

i tion may be carried to the liver by the pirtal blood. The tubercles 

V be disseminated irregularly tlirouL^i the liver and without rela- 

1 to the portal, hepatic, or biliary vessels. This is the case 

1 generally in miliary tuberculosis, in which, moreover, the tubercles 

" commonly too smill to be seen by the naked eye in the fresh 

.;in. The tulwrcles may, however, be in relation with the ])ortal 

tern, and may then be accompanied by fatty degeneration. Tuber- 

. - i of various sizes and in various stages of developnent may be 

met with also beneath the peritoneal covering, and in the portal 



182 TUBERCULOSIS OF THE ABDOMINAL ORGANS. 

canals. Tuberculosis of the portal canals may determine an over- 
growth of connective tissue and a form of hypertrophic cirrhosis, in 
which the liver is large, firm, and rather pale on section, and presents, 
in addition to the fibrous overgrowth w^hich penetrates into the 
lobules, a fatty infiltration of the hepatic cells. The cell is distended 
by one or more large oily drops which have pushed the nucleus and 
protoplasm aside. These changes may be general or limited to cer- 
tain areas, giving the liver a marbled appearance on section. Tuber- 
culous fibrosis of the portal canals may also produce atrophic 
cirrhosis. 

The symptoms, except in the rare cases in which atrophic cirrhosis 
develops and causes ascites, are not well marked. In hepatic tuber- 
culosis, occurring in the course of acute general tuberculosis or of 
peritoneal tuberculosis, there is some enlargement of the organ, which 
may be tender ; but, as a rule, symptoms referable to the liver are 
not Avell marked, though an icteric tint of the skin may develop. 
Hypertrophic tuberculous cirrhosis causes considerable enlargement 
of the liver, which is firm and has a distinct rounded edge and 
smooth surface. The spleen is enlarged. There is ascites. The 
urine is scanty and dark. It contains urobilin, often sugar, in pro- 
portion related to the carbohydrates of the food, and a diminished 
proportion of urea, while a trace of albumen may be present. Marked 
jaundice is rare, but the skin has an earthy tint, and there is often 
slight cyanosis. The face is pufpy, and there may be oedema of the 
lower extremities, upon which petechise may form. Haemorrhage 
may occur from the nose, stomach, or lower bowel, and the epistaxis 
in particular may be copious and obstinate. Sooner or later the 
lungs become infected, and many patients succumb to a rapid form 
of pulmonary tuberculosis. The temperature does not give any cer- 
tain indications, and unless the lungs or other organs are affected 
there may be no fever, or only slight and temporary elevations of 
temperature. 

The prognosis of tuberculous disease of the liver is exceedingly 
grave. As a rule, it is added to other tuberculous lesions, in them- 
selves sufficiently serious. Hypertrophic fibrosis due to tuberculosis 
can only be recognized w^ith certainty by its association with pulmo- 
nary tuberculosis, or by the appearances after death ; so that it 
appears unprofitable to speculate as to the chances of recovery from 
this affection. For reasons of the same order, the treatment of 
hepatic tuberculosis calls for little discussion. When part of a gen- 
eral tuberculosis it must be treated on general principles, and the 
treatment of hypertrophic fibrosis however determined, must be the 
same. 



CHAPTER XIII. 
PULMOXAm' TUBERCULOSIS. 

Acute Pulmonary Tuborcuh^is — Acute Tul>erculous Pneumonia — Acute Tuberculous 
Broncho-pneumonia — Chronic Puhuonary Phthisis — [Tuberculin] — General Re- 
marks on Treatment. 

Pulmonary Tuberculosis. — Pulmonarv tuberculosis m childrcu, as 
in adults, may be acute or chrouic. It is relatively connnou iu iu- 
fiincy, rare uuder four or five years, but frequent after that age. 

Three types of acute tuberculosis of the lum/s may be distin- 
guisiieil, presenting distinct pathological and clinical features : (1) 
If the infection be derived from the blood, the changes begin in 
the tissue of the alveoli, the capillaries, and the alveolar epithe- 
lium. The tubercles may be disseminated through both lungs when 
the pulmonary tuberculosis is often only a part of a general tu- 
berculosis ; or they may at first be confined to one lung, being 
either scattered more or less uniformlv throuo:h it, or closelv set in 
the upper or lower lobe. After the first outbreak the morbid proc- 
ess may be arrested, either temporarily or permanently, the indi- 
vidual tubercles eventually undergoing a fibroid change. ]More 
commonly the tubercles become caseous at the centre, while the 
tul)ercul<>us process extends at the periphery until by coalescence 
large tracts of the lung are involved, and undergo caseation and 
softening. (2) More rarely, the infection of one lung or one lobe is 
80 intense that the pulmonary tissue becomes densely ])acked witii 
tubercle. This is attended by catarrhal inflammation of the bron- 
chioles and alveoli and redema of the tissue intervening between the 
tubercles, so that an acute tuberculous pneumonia is produced. (3) 
If the infection takes j)lace by way of the bronchi — 'inhalation 
tuberculosis" — the resulting disease has the general })athologi('al 
character of broncho-pneumonia. The tuberculous process is then 
primarily jK*ribronchial, and the anatomical element involved is the 
lobule, though when the infection is intense so many adjacent lobules 
may l>e affected that the whole lobe, or a large part, may become 
consolidated. Retrogression and fibroid ciiange may occur, l)ut a far 
more common sequel of events is caseation, softening, and the clear- 
ing away of the disintegrated matter with the fi)rination of vomica. 
This api>ears to be the form whicii pulmonary tuberculosis commonly 

183 



184 PULMONARY TUBERCULOSIS. 

takes when it follows measles or whooping-cough, the bronchitis or 
broncho-pneumonia by which these specific diseases are so frequently 
complicated having prepared the bronchial and pulmonary tissues to 
receive the tuberculous infection. After measles, especially, it may 
be difficult to say at what stage the broncho-pneumonia becomes 
tuberculous. In some cases the child has already suffered from some 
chronic tuberculous affection of the lungs, the glands, or joints. 

(1) In acute pulmonary tuberculosis there is a widespread 
irruption of miliary tubercles in the lungs, and the symptoms are 
those of the bronchitis thus produced. Cough is troublesome, and 
the expectoration, if it can be obtained, will be found to be muco- 
purulent, and perhaps tinged with blood. There will probably be 
no deficient resonance on percussion ; the note may be indeed tym- 
panitic, a significant change suggesting the occurrence of emphysema 
to compensate for the areas of lung occupied by the tubercles, wliich, 
though individually minute, in the aggregate involve a large portion 
of the breathing space. Dyspnoea, which is a prominent, and often 
also an early symptom, must be attributed to the same cause. It is 
greater than can be accounted for by the physical signs, and these 
two conditions, if associated with some cyanosis of the lips, ears, 
hands, and feet, should excite suspicion of tuberculosis in any case 
in which the physical signs point to no more than bronchitis. The 
breath sounds may, however, be altered in some areas, generally at 
one base, or in the interscapular region, becoming harsh, bronchial, 
or tubular, and small crepitations, coarse mucous rales or sibili may 
be heard. Tubercle of the pleura may produce sounds which closely 
resemble true fine crepitations. The pulse is rapid, the temperature 
is 101° to 103° F., and the child is evidently far more ill than is to 
be accounted for by the extent of the physical signs. Enlargement 
of the spleen may be detected early in the most acute cases, and is 
usually to be observed at a later stage in the less acute. 

The prognosis in cases of this type is extremely bad. Many ulti- 
mately present cerebral symptoms due to the infection reaching the 
meninges ; others succumb to the severity of the pulmonary disease 
within a fortnight ; others survive for a month or even several 
months. This is perhaps observed with special frequency in cases 
following typhoid fever. 

(2) Acute tuberculous pneumonia, a rare affection at any age, is 
not often observed in children. 

The symptoms are identical with those of acute croupous pneu- 
monia, but crisis does not occur, the fever is usually less high, and 
after four or five days becomes irregular. Profuse sweats often 
occur at night, and there may or may not be diarrhoea. The per- 
sistence of the symptoms and of the signs of consolidation raise a 
suspicion of tuberculosis, and after two or three weeks, if the patient 



ACrTE TUBEECCLOUS BEOXCHO-ryEUMOyLi. 185 

lives so long, the signs of softening and of the formation of cavities 
may be discoverable. Before this, if the sputum is brought u}i, it 
will be seen that it is purulent and greenish, and the tubercle bacilli 
may be discovered, perhaps, in lai-ge unmbers. The diagnosis from 
pneumonia in the early stage is impossible. Later the persistence 
of the signs and symptoms, the irregular fever, and rai)id emaciation 
and loss of strength will justify an unfavorable diagnosis, even if 
tubercle bacilli be not discovered in the sputnm, nor tubercle in the 
choroid. The occurrence of cerebral complications (meningitis) will 
often confirm suspicions already entertained. 

{o) Acute tuberculous broncho-pneumonia is a common affec- 
tion in children. It is the form which ensues most often after measles 
and whooping-cough. It is prccetled in other cases by various ex- 
hausting diseases — gastro-intestinal disorders, chronic bronchitis, or 
reix^ated attacks of broncho-pnenmonia ; bnt it may come on sud- 
denly in the midst of apparent good health. It is lobular in distri- 
bution, though by confluence large areas of consolidation may be 
formed. These nndergo caseation and softening. The small bronchi, 
thickened by the tubercnlons process, are filled with caseous material, 
bnt with the progress of the softening and the onset of sn}i|)uration 
they are destroyed ; eventually small vomica or narrow anfractuous 
cavities are formed. These changes may be irregularly distributed 
through both lungs, or may be at first confined to one lung or to one 
part of it, generally the apex. In such cases death is often deter- 
mined by the rapid infection of the other lung, so that while in one 
lung we find caseous areas and cavities, in the other we find numer- 
ous tubercles in various stages, the majority gray or miliary. 

The signs and symptoms are those of l^roncho-pneumonia. The 
onset may l)e acute or subacute. In the former case the child, when 
convalescent from some febrile disease, while suffering from whoop- 
ing-cough, or after }x^rhaps a few days of peevishness and anorexia, 
becomes suddenly feverish (102°— 104° F.) and suffers from tronble- 
some congh. The resi)iration is hurried and tlie ])ulse quickened, 
but not in proportion, so that the pulse-respiration ratio is disturl)('d. 
The face is suffused or slightly cyanosed, and the skin is dry and 
harsh. The physical signs may be at first those of l)ronchitis only, 
with iierha]>s here and there, at the apices, at the posterior bases, or 
in the axilhiry regions, areas over which crej>itant and small mucous 
rales are heard. The percussion note is usually unaltered, or in the 
regions where the finer nlles are heard, a little high-pitched, with an 
increased sense of resistance to the jdeximeter finger. If the aj)ices 
are affecte<l by scattered patches of broncho-j)ncumonic consolidation, 
they may l>e tymj^anitic. Later there may i)e distinct evidenco of 
consolidation over more or less extensive areas, including generally 
I the apices. The condition of the child deteriorates rapidly, and 



186 PULMONARY TUBERCULOSIS. 

emaciation may become extreme ; there are sometimes copious sweats, 
and often diarrhcea. In cases of this class the patient seldom sur- 
vives long enough for cavities to form. Death may indeed ensue in 
a few days, and the tuberculous nature of the disease may only be 
established by careful microscopical examination of the broncho- 
pneumonic areas. 

Chronic pulmonary phthisis. — Chronic pulmonary tuberculosis 
(pulmonary phthisis), seldom seen in infancy, becomes after the age 
of three years progressively more common, until about the age of 
puberty it is not infrequent. It resembles in general characters the 
pulmonary phthisis of adults, and will not, therefore, be discussed at 
length here. The main peculiarities of chronic pulmonary phthisis 
in childhood are the frequency with which it is secondary to tuber- 
culosis of the bronchial glands, and the fact that — ^perhaps in con- 
sequence of this — the earliest lesion in the lung is commonly not at 
or a little below the apex, but in the neighborhood of the hilum. 

The symptoms are similar to those of the same disease in the adult. 
The chronic or insidious mode of onset is less common, for pulmonary 
phthisis in children ensues most often upon an attack of severe 
bronchitis, broncho-pneumonia, or pleuro-pneumonia. In such cases 
it is commonly impossible to determine whether or not the initial 
disease of the lung itself partakes of a tuberculous nature. When 
chronic pulmonary tuberculosis follows measles, the development of 
destructive lesions in the lungs may be very insidious, and the same 
character may belong to the disease when it develops in a child who 
has suiFered from repeated attacks of bronchitis or gastro-enteritis. 
Haemoptysis is very rare as an early symptom, and is not common 
in the later stages. Cough is often not severe, and there may be no 
expectoration, the sputum being swallowed. The child, after the acute 
illness — which, as has been said, usually marks the commencement 
of the disease — is found not to regain its former health. Though 
restless it is indisposed to play, is a little short of breath, and has a 
short, dry cough. It is ansemic, and there may be some general 
puffiness of the upper part of the trunk and of the face, which is pale. 
In the afternoon or evening there is some slight elevation of tempera- 
ture, accompanied by a malar flush and increased restlessness and 
volubility, and followed by perspiration and chilliness in the early 
morning. With these symptoms there are usually some loss of appe- 
tite and slight emaciation. The physical signs, except in those cases 
in which the tuberculous disease runs on directly from antecedent 
broncho-pneumonia, are at first often very indefinite. A difference 
in expansion between the two sides is not usually to be recognized 
except in cases in which the phthisis succeeds pleurisy. Gentle 
pressure with the finger tips in the intercostal spaces may elicit some 
tenderness. The percussion note may be high-pitched in some areas, 



CHROXIC PULMOXARY rHTHISIS. 187 

especially, perhaps, in the intei*scapular area, in the axilla, ov below 
the angle of the scapula. On the other hand, it may be, and often 
is, tympanitic at the apex in front, or, indeed, over the whole of 
one side, or over both backs. Vocal fremitus and resonance may 
be increased in those parts in which the resonance on percussion is 
diminished, or over wider areas, and the breath sounds may here be 
harsh and bronchial. A dry crackle may be heard at the ciul of in- 
spiration, but will often disappear temporarily after a deep breath, or 
after crying or coughing. Later, moist rales may be heard, and may 
l>e observed with the lapse of time, to become larger and more click- 
ing. Finally, cavernous respiration and rales may develop. Too 
much importance, however, must not be attributed to auscultatory 
signs of a cavity, since they may be simulated by bronchiectasis, 
which is produced rapidly in children. At the apex moist sounds, 
due to resolving pneumonia, sometimes, in thin children, have a 
hollow character, while at the same time the breath sounds are high- 
pitched so that a general resemblance to the physical signs of a cavity 
is produced. The dyspeptic troubles common in adults are often 
absent ; on the other hand, it is not uncommon to find that the chikl 
is very subject to attacks of gastro-enteritis, or suffers from chronic 
entero-colitis, with frequent offensive mucous stools. If the jnd- 
monary disease is very chronic, the general nutrition may suffer 
little, but such children are very liable to attacks of local pneumonia 
around the tuberculous area. These attacks are accom])anie(l by 
high fever, dyspnwa, and a sudden extension of the physical signs. 
As the fever subsides, the signs diminish again rapidly, and the con- 
dition may seem to revert to that which existed before the acute at- 
tack. In children under three years of age, the temperature may 
be little, if at all, raised for long periods together ; indeed a case m;iy 
be under observation for weeks without any elevation of temperature 
^»eing noticed. In other cases, and in older children as a rule, fever 
f hectic type is established early, though the maximum temperature 
may occur in the morning ; altogether, the temperature curve in a 
case of pulmonary phthisis in a child, especially a young child, tends 
to be more irregular than in adults. As a rule, when the disease has 
reached a stage in which the physical signs enable a jK)sitive diag- 
nosis to be made, the child rapidly becomes extremely emaciated. 
In some cases the aj)|)etite is retained to a wonderful extent into 
quite a late stage, and, in the absence of late diarrhcea, which is rehi- 
tively uncommon in children suffering from phthisis, the nutrition 
may be maintained to a degree whieh may lead to errors in jirognosis. 
[Tuberculin as a Diagnostic Agent. — Wliih- the therapeutie vahie «»f 
tulKTCulin is still snj} judioc^ its value in diagnosis nnist be admitted. 
This dejx-nds upon the fact that tuberculin when introduced into a 
tuberculous individual prrxluces in a few hours a " reaction " char- 



188 PULMONARY TUBERCULOSIS. 

acterized by rise of temperature, chilliness, cough, and general 
malaise. Xo such reaction is observed in non-tuberculous indivi- 
duals similarly treated. This test is now very generally applied in 
this country to all large herds of cattle, and its value to the public 
is universally acknowledged. Unfortunately the test is but little 
used with human beings on account of the prevalent fear of " unfet- 
tering " the bacilli from some latent focus with their subsequent 
dissemination over the whole system. Such dissemination, however, 
does not take place in cattle, nor did Koch, testing 1,000 cases in 
man, observe any such result. In view of these facts, a more ex- 
tended use of this valuable preparation in cases of suspected tuber- 
culosis is earnestly recommended, especially among children where 
the diagnosis is so often diflficalt or impossible in the earliest stages, 
the time at which treatment is most successful. 

Too great care in the selection of a preparation cannot be exer- 
cised. It should be of known quality and strength. The amount 
to be injected is variously given by different observers as one-twen- 
tieth of one milligramme in infants, up to from one-half to ten milli- 
grammes in adults. It may be injected in any part of the body, 
but must be injected deeply. A rise of temperature from 102.5° to 
104° with other general symptoms within twenty-four to forty-eight 
hours should be considered as a definite test. If there be no reaction 
after the first injection, the test may be repeated with gradually in- 
creasing amounts at intervals of four or five days, till three or four 
trials have been made.] 

General Remarks on Treatment. — The treatment of chronic 
tuberculosis, whether affecting the pulmonary or abdominal organs, 
is, in practice, most difficult. No drug has any power of arresting 
the progress of the infection ; but since the destruction of tissue is 
produced not only by the specific bacillus but also by pyogenic 
organisms, antiseptic drugs have, under favorable circumstances, a 
certain influence over the disease as a whole. Of these the most 
valuable is creasote [which may be given as follows : 

Creasoti, ttlss 

8pir. Rect., 

Spir. Chloroform,, aa lT\^ijss 

Tn. Card. Co., 

Extract. Glycyrrh. Liq., aa r(\y 

Mucil. Tragacanth., TT\^x 1 

Aq., ad 5j ^ 

Dose at 1 year. Appendix, ] 

On the whole, however, drugs are of value chiefly for holding in 
check secondary conditions which are undermining the strength. Thus 
morphine in linctus may be called for by cough which prevents sleep, 
bismuth by diarrhoea, belladonna or oxide of zinc by copious sweating. 



I 



i 



GEXERAL HEMAEKS OX TREATMENT. ISO 

[Liq. Morph. Hydroohlor., TTLi-iij 

Acid. Hydroohlor. Dil., TT\^j 

Tn. Aurantii Kec., tt^xx 

Give, n^x 

Aq., ad 3j 

For children over S years. Appendix. ] 

Arsenic is praised by Jacobi for its stinuilating effect on cell- 
growth. He finds its ** principal indication in the jx^culiar fiT.gility 
of the blood-vessel walls resulting in pulmonary hiemorrhage." He 
gives two minims of liquor arsenicalis daily in three doses, largely 
diluted, after meals, to a child of a few years old. The drug mav 
be continued for an indetinite perioil, unless symptoms of an over- 
dose — gastric and intestinal irritation and local cedema — appear, as 
seldom occurs if small doses of opiates are given with it. AVith 
arsenic he combines also digitalis,^ which he recommends (1) on ac- 
count of its influence in favoring the excretion of the kidney and the 
emptying of the veins, thereby accelerating the flow of lymph and 
improving general nutrition ; (2) because the pulmonaiy artery is 
relatively larger in childhood, so that any insufficiency in the heart 
muscle tends to produce cedema of the pulmonary tissue, a condition 
obviated by the improvement in the pulmonary circulation caused 
by digitalis ; and (3) on account of its action as a cardiac stimulant, 
since this is attended by improvement in the nutrition and develop- 
ment of the heart, which is relatively small in phthisis. He con- 
tinues the remedy for weeks or months, but, if a speedy action is 
required, combines with it strophanthus, sparteine, or caffeine. 

The (fif'i is an important element in the treatment of all forms of 
chronic tuberculosis. In pulmonary phthisis the appetite is usually 
small and capricious, while hectic fever and sweating, even if diar- 
rhiea Ix? absent, combine to reduce the patient's strength and to 
waste his ti.ssues. In young children milk should be the staple 
anicle of diet, but care must Ik? taken to obtain it from a source free 
fn»m tul^erculous taint. Meat, either raw or very lightly cooked 
and scrajKd to a fine pulp, is a valuable addition, and I)el)ove praises 
a methoil of '* forced feeding'' by finely powdered dry meat intro- 
duce<l directly into the stomach. In older children a greater variety 
in the diet is requisite, and means must be taken to overcome 
the distaste to fatty foods, wliich is often very marked. Cod-liver 
oil is the most effective form in which fat can be given. It is l>est 
taken alone, or with malt extract, and if of gr>od quality the patient, 
as a rule, sfxm becomes reconciled to its taste; indeed, many children 
acriuire a great liking for it. When the repugnance to it is great it 

' '* Therapeutics of Infancy ami ( hildhood," by A. .Jacobi, M.D., etc., Philadel- 
phia, 18%, He re<ommenfU, in preference to the infusion or tincture, which are 
often not well bc»me by the stomach, a lifpiid extract, or extract — TT\^ij of the former, 
or f^. of the latter, for a child a few years old, daily. 



190 PULMONARY TUBERCULOSIS. 

mav be given as an emulsion, and then, after time, the pure oil will 
fTonerallv be tolerated. Eructations some little time after swallow- 
ing the oil, of which many patients complain more than of the taste 
of the oil itself, are best corrected by taking some carminative, such 
as peppermint, shortly after the dose of oil. Cod-liver oil should be 
given after meals, and must usually be intermitted during any febrile 
attack. 

The point of prime importance, however, in the treatment of 
chronic pulmonary phthisis is that the patient should at all times 
breathe fresh air ; other climatic conditions — temperature, moisture, 
elevation above the sea — are of secondary consequence to this. The 
patient should be under strict discipline as to habits of life, time 
spent in the open air, food, clothing, etc., and the necessary condi- 
tions are best fulfilled at a sanitarium, of which many exist in Ger- 
many. Prolonged treatment is necessary in most cases before any 
permanent improvement can be looked for. In the case of quite 
young children, or in older children when treatment in an institution 
is impossible, the patient should be put under the best obtainable 
hygienic conditions, should spend as much time as possible in the 
open air without fatigue ; and the rooms used, especially the bed- 
room, should be kept scrupulously free from dust, and should contain 
no heavy hangings nor much furniture. The sputum should be dis- 
infected and destroyed, and soiled linen should be disinfected. This 
prophylactic treatment is to^ be recommended both'in the interest of 
the patient and of other members of the family. The patient should 
not be nursed by a person suffering from active phthisis, and the 
fact that consumption is a disease which may easily be communicated 
under ordinary circumstances of domestic intercourse between chil- 
dren and parents should be impressed upon the latter. 



!l 



CHAPTER XIV. 
SYPHILIS. 

Inherited Syphilis; Infection ; Symptoms ; Lesions ot'Skin ami Miu-ous Mtinl)i;»nos, 
of Viscera, of Bones; Contagiousness — Late Syphilis — Diagnosis of Inluritid 
Syphilis — Prognosis — Aajuired Syphilis — Treatment of Syphilis. 

Syphilis in infancy may be inliorited or acquired. In tlie large 
majority of cases it is inherited. 

Inherited Syphilis. — Infection of the ovum with syphilis, which 
may take place at the time of conception, may result in the death of 
the fcptus before birth, and consequent abortion ; in the birth, at or 
before term, of a dead child ; in the birth nf a livino: child suffering 
from cachexia, with or without certain characteristic lesions of the 
.skin ; or, in the birth of a well-nourished living child, which a few 
weeks later presents the skin lesions, with or without marked 
cachexia. 

For three, or at most five years after his chancre, the father may 
infect the mother in the ordinary way, and both parents then suffer 
from obvious syphilis. The father may infect the foetus as late as 
twenty years after his chancre, when for years he has presented no 
manifestations of syphilis, and the mcjtlier may have a series of 
syphilitic pregnancies, resulting in miscarriages or in syphilitic 
infants, without at anytime herself presenting any syphilitic mani- 
festations ; but she does not contract syphilis from her own child 
(Colics' law). In the same couple the severity of the infection trans- 
mitted to the fretus tends to decrease with succeeding ])regnancies. 
Thus it is the rule for a woman to have at first several abortions, 
then perhaps a child born dead, then a living child which suffers 
from inherited syphilis. Children born later usually suffer less 
severely ; but this 'Maw of decrease" (I)idayj is not with(»ut numer- 
ous exceptions. Sometimes the third or fourth child suffers more 
tiian the second, and it has been alleged that in some families chil- 
dren of one sex suffer nK>re severely tlian those <»f the op|)osite. In 
twin pregnancies one child may be affected whih- the other aji- 
parently escaj>es. The apparent escape of the mother <»f sy|)hilitic 
infants by a syphilitic father has been accounted for on the sujiposi- 
tion that she undergoes a mitigated infection derived from the fcetus, 

11)1 



192 SYPHILIS. 

but, as Coutts^ has pointed out, the theory that she absorbs from the 
foetus a syphiHtic antitoxin would account not only for her own ap- 
parent immunity but also for the gradual decrease of the severity of 
the disease in later pregnancies. A man under proper treatment 
may beget a healthy child, and later, having given up treatment, an 
infected foetus. If the mother be infected but not the father, death 
of the foetus is the most likely event; but if the child is born alive it 
will probably suffer from inherited syphilis. If both parents have 
suffered from manifest syphilis, the chance of abortion or still-birth 
is greater. Practically, however, the question whether a child 
brought for treatment has derived its infection from father or mother, 
or both, is not one of much importance in prognosis, which must rest 
mainly upon the condition of the infant itself, especially as to 
nutrition. 

The main symptoms are marasmus and anaemia and certain lesions 
of the skin and mucous membranes. At birth the infant may be 
well nourished or already puny and emaciated, but as a rule there 
are no distinct manifestations. If these be present, death ensues al- 
most without exception in a few days. In a typical case the infant 
is fairly well nourished at birth, but does not thrive well, becomes 
anaemic before the end of the first month, and during the course of 
the second month begins to suffer, first from snuffles, and then from 
an eruption. The appearance of the symptoms may be delayed until 
the third month, or even to the sixth month ; only in exceptional 
cases to a date later than this. An infant may be born, either alive 
or dead, with more or less extensive pemphigus, or it may be born 
without the eruption, which appears during the first, more rarely in 
the second, week of life. It comes out first on the palms and soles, 
or other parts of the feet and hands ; the face is less often affected, 
the trunk rarely. The bullae are surrounded by a red zone, or seated 
on a dusky red, slightly elevated base. Usually they are flaccid, and 
contain pus and blood ; but in the less severe cases the fluid may be 
clear and the bullae tense. The nail-bed is often diseased, leading 
to blackening and destruction of the nail, or to a deformity of the 
nail, which is narrow at the base and spread out like a fan at the free 
end. The bullae, when they rupture or dry, form dark yellowish- 
green scabs, often, from confluence, of large size, under which a shallow 
unhealthy ulceration tends to spread. The child is usually marasmic 
at birth, or very quickly becomes cachectic, and the prognosis is 
extremely bad. This eruption, when well marked, indicates a very 
severe form of the disease, but Crocker^ states that he has seen one 

' " Some Aspects of Infantile Syphilis," London, 1897. These Hunterian Lectures 
contain an excellent discussion of many of the moot points as to syphilis, both inherited 
and acquired in infants, 

2 ''Diseases of the Skin," London, 1893, p. 544. 



ISHERITED SYPHILIS. 



193 



severe case, in which the eruption was present at Mrth, ivocner und(>r 
immediate mercurial treatment. Tsually the intants succumb quickly 
to the cachexia. Occasionally cases are met with in which a few 
shallow bulhe appear as late as the fourth or fifth week of life. Such 
cases are amenable to mercurial treatment, and the ])rognosis is much 
better. 

Fig. 14. 




_ ^.r-rA'aV-^. 



Syphilitic mara&niiis in an infant, showing the senile cast of couuteuaucc, ihugudL's about the 
mouth, etnaciatioD, inelastic skin, scanty hair, and ansemic rcdema of bands aud feet. (From a 
photograph. ; 

The marasmus produced ])y inherited syphilis (Fig. 14) may be 
the first symj>tom in time as it is in importance. We may distin- 
guish two factors — anaemia and wasting. The infant may be })orn 
marasmic, or it is lx)rn well nourished, but before the end of the first 
month begins to be ana?mie. The skin has a faint yellow or straw- 
colored tinge, and looks semi-transparent, as though it wore coated 
with a thin layer of yellow wax. W'lien the affection is more j)ro- 
found the color \s> deeper, and the skin has an opaque brownish tint, 
13 



194 SYPHILIS. 

which has been compared to that of cafe au lait. The hair grows thin, 
and a shght branny desquamation, often accompanied by yellow 
stains mav be seen about the scanty eyebrows. Usually the first lo- 
cal symptoms is snuffles, due to a lesion of the nasal mucous mem- 
brane, attended by much secretion and, after a time, by swelling, so 
that the nasal passages become blocked, and the infant, in consequence, 
has difficulty in suckling. Xext, one of the various forms of skin 
eruption appears generally first about the buttocks or round the mouth. 
The anaemia, which is due to a decrease in the number of the red 
blood-corpuscles and in their haemoglobin, is, in my experience, al- 
ways present to some extent before the eruption appears. It is 
usually accompanied by wasting. If the infant is suckled at the 
breast, this may not be great ; but in those fed artificially it is always 
considerable and often extreme. Marasmus may continue after the 
eruption and even the snuffling, which is more persistent, have dis- 
appeared under the influence of mercury. It may be the only 
symptom at the time advice is sought in cases in which the family 
history, or the history of snuffles and rash which passed away after a 
short time, leaves little doubt that the infant is the subject of he- 
reditary syphilis. Again, obstinate ausemia, Avith or without wasting 
may be the only symptoms in the later born infants of a family known 
to be syphilitic. 

If, either soon after birth or at a later date, the marasmus 
have become well established, it is too often the case that mercury 
has little effect. The intestinal mucous membrane is extremely 
wasted, so that the wall of the gut is as thin as writing paper, and 
to the naked eye seems to consist only of the peritoneal coat, with a 
very thin mucous lining. The liver also is often fatty, and it is 
clear that diQ:estion, absorption, and assimilation are all most imper- 
fect. 

The lesion of the shin most often seen in the early stage is ery- 
thema, but papido-squamous, papular, vesicular, or pustular eruptions 
may take its place. Later lesions of the mouth are mucous tubercles 
and the so-called syphilitic furuncle. The sy})hilitic roseola, which 
is the commonest eruption in acquired, is rare in inherited syphilis. 

The conditions to which the term erythema is applied is a super- 
ficial hypersemia with slight infiltration. It is commonly either lim- 
ited to parts liable to irritation by discharges or clothing, or is most 
marked in these situations. The skin is reddened, a little thickened, 
and the finer natural markings are obliterated. It begins, as a rule, 
as patches on the buttocks and soles of the feet. It spreads by the 
formation of new patches in the healthy skin, which enlarge until 
they coalesce with each other and with the older areas. It extends 
often over the whole of the posterior aspect of the lower limbs and 
feet, so that the infant looks as if it had walked and sat down in a 



INHERITED SYPHILIS. 195 

pudtlle of red dye. It may extend on to the trunk, in a eontinuous 
sheet behind, but in patehes in front, and its upper limit often eorre- 
sponds distinetly with the maroin of the napkin. On other parts 
of the trunk, at the folds of the axilla and of the neck, about the 
mouth and behind the ears, patehes are often to be seen (Fig. 10). 
Occasionally the eruption extends over the whole body ; infants thus 
extensively at^eeted seldom reecn'er. On parts of the skin moistened 
by perspiration or urine the surface is smooth, glistening, and of a 
red brown or copi>ery red color. On the drier parts the color is less 
deep, and there is some desquamation, which is usually detached in 
small Hakes. On the soles of the feet it may separate in larger 
flakes, leaving the whole surface smooth, and deep red with a frill 
of half detached epidermis at the edge. An eruption which rather 
resembles this, but is held to correspond with the pap ulo -squamous 
eruption of acquired syphilis, consists of smaller patches, of a lighter 
red or yellowish color, with more infiltration and a more copious 
desquamation. Such patches tend to heal in the centre, and then 
present a thickened red edge, and a flat faintly yellow centre. When 
small, few in number, and situated on the face, temples, or neck, this 
condition has, it is said, been mistaken for ringworm. The patches 
may spread far and wide, coalescing at their edges, while healing at 
the centres, thus forming geographical patterns. 

The eruption may be papular. The most characteristic form is a 
flat papule, roundish or of irregular angular outline, with a dusky 
red hue and a shining surface. The papules occur in groups or 
singly, generally on the neck, shoulders, or arms, and are often asso- 
ciated with erythematous or pustular lesions about the buttocks. In 
other cases, and, according to Crocker, more often, the papules are 
small, convex or acuminate, of a bright or brownish red, and crowned 
with a scale or a small pustule. They occur in irregular groups on 
the limbs, and are almost always in ray experience associated with 
pustular or ulcerated lesions of the buttocks and face ; and their 
specific nature is often doul)tful — tliat is to say, they commonly ap- 
pear to Ix? due to secondary pyococcal infection in a syphilitic infant. 

Upon parts which are constantly moist, and especially in infants 
who are not very carefully nursed, any of the skin lesions already 
mentioned may be complicated by sujipm-ation. Thus shallow ulcer- 
ation on the buttocks often occurs in erythema, and al)out the mouth 
crusts may form under which a creeping ulceration sj)reads slowly. 
Ecthymatous sores may form on the buttocks, face, or arm, and a 
greenish crust covers a sharp-edged uhcr, which exudes a thin 
greenish or sanious pus. These supi)U rating lesions are jissociated 
"with secondary infection by pyogenic organisms, and the infective 
material carried to other parts of the body may excite a widespread 
imix'tigo. 



196 SYPHILIS. 

The syphilitic eruptions ^vhen they fade leave some discoloration, 
the depth and permanency of which is in relation to the severity of 
the lesion. 

The lesion of the skin to which Barlow has applied the term 
syphilitic furuncle is a manifestation Avhich appears later than the 
eruptions hitherto mentioned, as late even as the fifth or sixth year. 
It is often met with, and is exceedingly characteristic. The term 
'^ blind boiP' applied to it commonly by mothers w^ell indicates its 
general character. An indolent swelling involving the whole skin 
forms slowly without any lesion of the surface, w^hich, however, 
gradually assumes a purple color. The swelling, which eventually 
may be half an inch in diameter, then contains a few drops of thin 
pus. Untreated it may persist for months, finally undergoing retro- 
gression, leaving some thickening and puckering of the skin. If 
irritated, it may break down at the surface, forming a shallow ulcer 
on a thickened base. Under mercurial treatment it disappears 
rather slowly, leaving no scar. The inner and outer aspects of the 
thighs and the front of the abdomen are the most frequent sites of 
these lesions. They are not pathognomonic, as similar cutaneous 
lesions may be observed occasionally in cases in which no history of 
syphilis can be obtained, but they afford very strong confirmatory 
evidence. 

The situation and distribution of the skin lesions are determined to 
a very large extent by local sources of irritation (Fig. 15). It is 
for this reason that the buttocks, w^hich many times a day are in 
contact with urine and fseces, and the lower lip, which is kept wet 
Avith saliva if the infant dribbles, are so frequently the parts first 
and most severely affected. If the parts are kept dry and clean, the 
skin lesions may even disappear without specific treatment ; and, 
speaking generally, the skin lesions in infants who are well cared for 
are less extensive and persistent than in those constantly dirty. 

The mucous membrane affected earliest is that of the nose. It be- 
comes swollen, and a sero-purulent discharge is soon established, 
which excoriates the upper lip and cakes about the nostrils. The 
obstruction to respiration thus produced causes " snuffles/' which 
commonly precede the eruption by a short time. If the nasal lesion 
be severe and long lasting, some arrest of growth of the cartilage 
ensues, so that the nose is stunted but broad at the base. Per- 
manent deformity may result, but as a rule the nose gradually im- 
proves in shape as the child grows. Snufiles often persist long after 
the skin affections have disappeared under treatment. This is no 
doubt due, in part at least, to the great liability of the nasal mucous 
membrane in infants to catarrh, owing, perhaps, to the fact that they 
breathe altogether through the nose. Indeed, the acute coryza, 
which is very common in infants, and is often associated with laryn- 



INHERITED SYPHILIS. 197 

gitis, mav, if the patient bo seen first when the attack is subsiding, 
k»ad to an ungrounded susploion of syphilis. The hirvnx is often 
atlected soon after the nose, and the ery becomes toneU\-s, hoarse, ov, 
as it were, whis[)ering. Sores in the mouth arc rare in the early 
stage, but occasionally a superficial glossitis occurs simultaneously 
with the erythema of the buttocks, which indeed it much resembles ; 
the tongue is of a uniform beefy-red color and smooth, or it ]u*cscnts 
a few very superficial linear ulcers. A little later, in association 
with either ulceration of skin lesions on the face or mucous tubercles 

Fig. 1.">. 




Drawing (semi-diagrammatic) of a well-nourished infant presenting an extensive, dry, des- 
quamating syphilitic eruption, to illustrate the distrihutinn of the eruption in regions specially 
liable to irritation by friction (upj>er arm, knet-s) or by secretions i buttocks, ncvk, mouth). The 
ai.rnt.r .rr.-,t .f , l.vel Corresponding to the upfn-r edge of the napkin is well seen. 

in tiic moutii, shallow linear ulcerations affecting the red margin of 
the lips and the adjacent mucous membrane form, especially about 
tlir angles of the mouth. 

Mucous tubercles are a later manifestation. They appear u>ually 

■ »m the sixth to the twelfth month of life, and are apt to recur for 
lour or five years. They are met with especially alxiut the angle 
of the mouth an<l the anus. A.s.sociated with them deep cracks may 

•rm at the angle of the mouth, j)roducing the well-known rhagades, 



198 SYPHILIS. 

which arc often very obstinate and leave permanent scars. At the 
anus the condylomata sometimes break down^ forming very deep 
ulcers with thickened edges, which are concealed until the nates are 
separated ; in other cases, in older children especially, cauliflower 
excrescences may form. 

The spleen may be enlarged at the time of birth, and may so con- 
tinue for many months ; not very infrequently the enlargement com- 
mences later than the eruption, or after it has disappeared. Sooner 
or later it occurs in a large proportion of cases,^ but after the first 
year, rickets is so common in children who have suffered from 
syphilis that the enlargement in them may with equal propriety be 
ascribed to the rickets. AVhen the organ is enlarged the infant is 
always anaemic, but it may not be enlarged in extreme marasmus. 
The enlargement is due to hyperplasia, and the organ is firm and 
hard. In rare cases there is some adhesive peritonitis (perisplenitis). 

Interstitial hepatitis may be present at birth, but may not cause 
obvious increase in the bulk of the organ. It is difficult to speak 
with any confidence of the proportion of cases in which any enlarge- 
ment of the liver occurs, since it is not easy to prove that an ap- 
parent slight enlargement of the organ is real. The interstitial 
hepatitis may be attended by some atrophy of the hepatic cells 
and fibrous overgrowth in the portal canals. It may lead to jaun- 
dice, usually slight but occasionally intense, seldom or never to 
ascites, which, however, may occur in association with gummata in 
later childhood, a rare event. 

Gummatous inflammation and sclerosis of the intestinal mucous 
membrane hav^e been observed post mortem in infants dying soon 
after birth ; but the clinical importance of such lesions is not great. 
Intractable diarrhoea occurs in many cases of syphilitic marasmus, 
to the production of which it no doubt contributes, but in such cases 
no lesion of the intestines is found beyond w^asting of the intestinal 
mucous membrane. 

Specific lesions of the lungs are observed in the bodies of children 
born dead or dying soon after birth ; either fibroid induration with 
gummatous inflammation, or the '^ white pneumonia," in which 
patches of white hepatization are seen. 

The lymphatic glands, unless the syphilitic eruption be complicated 
by suppuration, are, as a rule, little enlarged. Small shotty glands 
may be felt in many cases behind the ear, in the axilla, groins, or 
neck, and may persist for a long time. 

The central nervous system is very seldom involved in infantile 
syphilis. Convulsions, retraction of the head, and opisthotonos have, 
on somewhat doubtful grounds, been attributed to syphilis. In 

' Dr. Gee found it in 45 per cent., Dr. Coutts in 62 per cent., and in 19 percent, 
in addition the organ was probably enlarged. 



ly MERITED SVPHILIS. 



199 



marasmic infants insomnia is soniotinios a vorv proniinont symptom. 
The infant is drowsy l\v day, but by nioht is restless, erying ahnost 
withont eeasing, and sometimes sereaming, as tliough in severe pain. 
At a somewhat later aire paehymeuiniritis, eerebral sclerosis, and 
gummata may occur. Hemiplegia is in some few cases ]n'odnced 
independently of the last-named lesion. Chronic hydroee]^lialus is, 
in rare cases, due to syphilitic disease of the membranes in the neigh- 
borhood of the fourth ventricle. The enlargement of the head is of 
the form nsually observed in chronic hydrocephalus (see Chapter 
XLI.), but it seldom attains great proportions. The photograph of 

Fig. 16. 




Hydrocephalus in a syphilitic infant 



an infant (Fig. IG), in whom the enlargement was arrested while 
under the influence of mercury, shows the broad pear-shaped cranium, 
the flattened shallow orbits, and the depressed eyeballs. If the 
cranial bones are affected In- tlie jx^'riosteal changes described below, 
the api>earance may be extremely odd, as in the infant a photograph 
of whom is reprrKluced in Fig. 17. In this case the orbits were 
shallow, the sderotics visible al)ove the cornea, and the eyeballs de- 
presse<l. The anterior fontanelle was large, and extended forward 
on to the forehead between two enf>rmous frontal bosses, while the 
parietal bones were pushed outward and much thickened at their 



200 



SYPHILIS. 



upper edges. Children suffering from late syphilis are backward, 
and sometimes distinctly deficient in intellect. 

Bone lesions, periosteal or epiphysial, occur in a very large propor- 
tion of all cases of inherited syphilis. According to Wagner, Birch- 
Hirschfeld, and other pathologists, epiphysial changes are present in 
all infants who die while suffering from the disease. 

Osteoplastic periostitis producing a layer of porous osseous tissue 
occurs in the foetus, and may be present at birth. The process may 
continue after birth, rendering the shafts thick, but true sub-peri- 
osteal nodes of the long bones, recognizable during life, are exceed- 

FiG. 17. 




Hydrocephalus in a syphilitic infant, showing bossing of cranial bones. 



ingly rare in infants, and rare in older children. On the bones of 
the skull thickenings of periosteal origin are very common. They 
occur most often on the frontal and parietal bones, close to the ante- 
rior fontanelle, and not, as in rickets, on the frontal and parietal 
eminences. When large they form thick bosses on either side of the 
fontanelle, and if the thickening extends on to the forehead so that 
the site of the interfrontal suture is marked by a deep groove, the 
appropriateness of the descriptive term, ^^ natiform skull,^^ applied to 
the condition by Parrot, is very striking. Post mortem the thickened 
bone is found to be soft and porous, so that it can easily be cut with 



INHERITED SYPHILIS. 201 

a knife, and vascular. The marii'in of tlie boss may he well defined, 
or the larger part, or the whole of the bone or, indeed, of the skull, 
may be thick and vascular, the changes being greatest at the bosses. 
The lesion does not appear to cause pain, and the bones are little, if 
at all, tender. The bosses disappear usually about the end of the 
first year, and leave no trace, but are in many cases succeeded by 
rickety changes. In a few cases they have been known to suppurate 
and necrose. At a later age, seven years or older, a clu'onic gum- 
matous periostitis may occur, especially of the tibia and palate, pro- 
ducing much thickening and deformity. 

In epiphysitis the part affected is the proliferating layer at the 
junction of the diaphysis with the epiphysial cartilage. There is an 
excessive and irregular proliferation of the cartilage cells of the 
<>steog:enic layer, which undergo degeneration, and by interference 
with the vascular supply produce more or less extensive necrobiosis. 
The affected layer api)ears as an irregular yellow line, and the bony 
lamell.T of the adjoining part of the diaphysis are thin. If the de- 
-rruction of tissue at the epiphysial line is sufficiently great the 
piphysis may be detached, and when recovery ensues may become 
united to the shaft in a faulty position. In a few cases suppuration 
ensues upon the necrobiotic process at the epiphysial line, and then 
distinct grating may be perceived when the limb is handled. Sup- 
puration is rare in infants except in the phalanges (dactylitis syphi- 
litica). Epiphysitis, as has been said, may be present at birth, l^ut 
it seldom pn^duces discoverable swellings before tlie third montli, 
more often a little later. The swelling is rather farther from the 
joint, and involves the end of the shaft more than in rickets, though 
it may be accompanied by effusion into the joint. Tlie distal ends 
of the lx>nes are more often affected than the proximal, the common- 
est sites being the lower end of the humerus, radius, ulna, femur, 
and tibia. The upper extremities are affected more often than the 
lower, and though the limbs on both sides may be attacked, showing 
a general symmetry, the lesion is commonly more severe in one bone 
than in others, or than in its fellow on the oj)posite side. 

Associated with the epiphysial disease there may be complete loss 
of power in the affected limb, which lies or hangs flaccid and motion- 
less in complete extension. At first there is some swelhng of tlie 
limb, but later there may be a good deal of muscular Masting. As 
a rule, one limb only is affected, generally an upper limb, but oc- 
asionally two, and in rare cases all four limbs are attacked. Pas- 
sive movement on handling of the limb causes pain, and it is 
onstomar}' to attribute the loss f)f power to the pain att<'ndiiig the 
piphysial disf-ase, and the wasting of the muscles to disuse, whence 
iie term pseudo-paralysis. It is an early symptom, sometimes the 
irliest, and has occurred in the first week. The most usual age is 



202 SYPHILIS. 

three or four months, but it has been seen as late as eight months. 
Distinct swelling about the epiphysial line may be absent, but tender- 
ness is rarely or never wanting, though it may be slight and not dis- 
tinctly limited to the neighborhood of the joints. Certainly in some 
cases it does not seem to be sufficient to account for the complete 
loss of power. Henoch doubts the connection, and the suggestion of 
Coutts that the paralysis and wasting may be due to peripheral 
neuritis is worthy of consideration. Kecovery is usually rapid under 
treatment, but relapse has been known to occur. 

The most different opinions have been held as to the contagious- 
ness of inherited syphilis. CoUes and Diday, for example, believed 
that it was more contagious and more virulent than the acquired dis- 
order. Other writers of equal authority have held the opposite 
opinion. It is certain that instances in which syphilis can be proved 
to have been contracted from an infant suffering from the inherited 
disease are exceedingly rare ; and it is possible that the contrary 
opinion may have been due to a failure to discriminate between ac- 
quired and inherited syphilis in infancy. 

• Late Syphilis. — Children Avho have suffered from syphilis in in- 
fancy are left in a condition of impaired health and nutrition, and are 
specially liable to succumb to some one of the many acute diseases, 
such as broncho-pneumonia or measles, to which their age is liable. 
A large proportion suffer from rickets in the second year. In some 
the normal rate of growth is checked, body and mind are stunted, 
and puberty delayed. At the age of ten to twelve years, or a i^w 
years earlier or later, signs of late syphilis appear in certain cases. 
The eye is the organ most often attacked, the commonest lesion be- 
ing interstitial keratitis. One eye becomes tender, waters, and there 
is some photophobia ; then the cornea becomes steamy and, finally, 
vascular, so that it has a pink-gray tint ; gradually the pink color 
fades, the cloudiness clears away, and the cornea becomes almost or 
quite clear. Meanwhile the other eye has probably begun to pass 
through a similar series of changes, and for a time the vision may 
be no more than perception of light. Associated with the keratitis 
there may be iritis. Choroiditis, evidenced by patches of pigmenta- 
tion and atrophy, may develop independently of keratitis. Sudden 
or gradual loss of hearing, without otitis and due probably to labyrin- 
thine disease, ending in loss of hearing for the speaking voice, is oc- 
casionally produced. The teeth are liable to various lesions, but the 
characteristic deformity, described by Mr. Hutchinson, is a stunting 
of the upper central incisors (of the second dentition), which are peg- 
shaped, with a notch in the centre of the cutting edge. These three 
lesions, keratitis, deafness without otitis, and the peg-shape of the cen- 
tral incisors, form the " triad of Hutchinson.'^ The other lesions occur- 
ring at this period are gummatous or sclerosing inflammations affect- 



LATE SYPHILIS. 203 

ing the bones, skin, throat and pah\to, brain and meninges, nose, liver, 
spleen, kidneys, testicles, lungs, and spinal cord. 

S}inovitl< may oecur under various forms. ' In one fluid is etVused 
very rapidly, generally into both knees. The aifeetion may be mis- 
taken for rheumatism, but the effusion is almost ]>ainless, and disap- 
pears quickly under antisyphilitic treatment. Ktl'usion into joints 
may take place also as a complication of osteitis, and as a conse- 
quence of gunnnatons synovitis. 

How many patients who have suffered from the early present also 
the latter manifestations cannot be stated, but it is certain that late 
syphilis is uncommon when compared with the frequency of inherited 
syphilis in infancy. 

The diagnosis in a well-marked case of inherited syphilis in in- 
fiincy can hardly be in doubt. In all obscure cases the history of 
the mother's pregnancies and the fate of other children of the family 
should be inquired into. A history of a series of abortions, or of 
children born dead or dying soon after birth, will alone excite legit- 
imate suspicions, for a woman who has had children born dead 
owing to pelvic deformity will probably be aware of the fact, and 
hasten to communicate it. 

The acute cori/za of infants usually follows exposure, and is at- 
tended by rise of temperature, sneezing, and is often complicated by 
laryngitis or bronchitis ; as has been said, doubt may arise if the case 
is first seen when the corvza is subsiding. Search should be made 
for any skin lesion, as, for instance, erythema of the soles, and branny 
desquamation about the eyebrows ; and attention should be directed 

the existence of anaemia, the sallow complexion of syphilis, or to 
enlargement of the bones. In the absence of any confirmatory 
symptoms, the physician will be well advised to keep his suspici(>ns 
to himself, though it is often prudent to begin antisyphilitic treat- 
ment even before the appearance of distinct manifestations, which, 
however, will probably not be long delayed. 

In young infants who suffer from syphilitic marasmus without 
other manifestations of the disease, the diagnosis must rest mainly 
upon the family history, and must Ijc largely conjectural. At a later 
age a history of snuffles and rash may be obtained. The only symp- 
tom which is at all characteristic is nocturnal insomnia, and when 
this symptom is marked in a wasted infant who is judiciously fed, 
mercury ought not to Ix,' withheld. Even if the insomnia be due, as 
is sometimes the case, to the uric acid diathesis, it will probably be 
rf'lievcil by a judicious course of gray ])owder or calomel. 

With regard to richdjt, remembering the early age at which syphi- 
litic Ixme fhanges, as compared with those due to rickets, c<immonly 
iM'L'in, the question in diagnosis is usually rather to recognize the 
' H. B. Robinson, Bri(. Med. Journ., 1896, vol. i., p. 1191. 



204 SYPHILIS. 

syphilitic basis of the rickets than to distinguish between two morbid 
processes wliich in the second and third years of life may be inextri- 
cably blended/ \yhen the question arises it may be remembered that 
the swelling in syphilitic epiphysitis lies rather farther from the joint 
than in rickets, and in advanced cases the grating between the 
diaphysis and epiphysis may be detectable and decide the question in 
favor of syphilis. 

Confusion can seldom arise between pseudo-paralysis and acute in- 
fantile paralysis. The age of the patient, the family history, the 
existence of syphilitic lesions of the skin, and the swelling of the 
epiphyses will usually suffice to prevent error. 

Perleche, an inflammatory disorder of the red margins of the lips, 
produces cracks at the corner of the mouth, but these are more acute 
and less deep than the rhagades of syphilis, and the affection occurs 
usually in epidemics in schools or institutions in which many chil- 
dren are brought together. 

The prognosis in inherited syphilis is often at first uncertain. Set- 
ting aside pemphigus, it is safe to say that the prospects of recovery, 
so far as the skin lesions afford any indication, depend rather on the 
extent than on the nature of the lesions. At the same time, a very 
scanty eruption associated with much marasmus and wasting is of 
bad omen. The condition of nutrition is by far the most important 
element in prognosis, but even on this head a confident opinion can- 
not be formed until the effects of treatment have been observed. 
Sometimes even when emaciation is extreme the organism responds 
rapidly to mercury, and in a few weeks the infant increases extraor- 
dinarily in weight. If after a fortnight of systematic treatment the 
weight has not increased, the prognosis is bad, whatever the effect 
may have been on the skin. Marked enlargement of the liver and 
spleen is an unfavorable symptom, and the occurrence of jaundice is 
followed in almost all cases by death. The occurrence of pseudo- 
paralysis does not seem to aggravate the prognosis, and if the child 
survive the severity of the affection as it affects other organs, com- 
plete recovery in respect to the loss of power may be promised in 
those cases in which effective treatment can be applied. 

In late syphilis the prognosis depends entirely on the extent and 
situations of the lesions. As a rule, recovery from interstitial kera- 
titis is practically complete so far as vision is concerned, whereas the 
graver forms of retarded development with deficient intellect, upon 
which treatment has little or no effect, commonly leave the patient 
permanently crippled in mind and body. 

Acquired syphilis in infants is identical in its manifestations with 
the acquired syphilis of adults. It is a less severe disease than in- 
herited syphilis, to which it presents a general resemblance, but with 
^ Conf. Shattock, Trans. Path. Soc. , vol. xlii. , p. 235. 



ACQUIRED SYPHILIS. 20r^ 

certain differences. In the first place, there mnst be a primary lesion 
(chanci'e). Even if the ease he in a later staije, evidence of its ]>rcvi- 
ons existence Avill prohahly be discoverable. This is an important 
point to bear in mind if the qnestion of the transmission of syphilis 
bv vaccination arise. In connection with the primary lesion there is 
considerable enlargement of the lymphatic glands. The first skin 
lesion is nsnally the I'oseola commonly seen in adults, and anv sub- 
sequent eruption is usually scanty. The infant does not snutHe, or, 
at any rate, this is not an early and prominent symptom as in the 
inherited disease. On the other hand, the throat is often affected, 
and condylomata apjx'ar early, persist long, and arc often luxuriant. 
The eruption has not the peculiar characters of that seen commonly 
in the inherited form, in particular the erythema of the feet and palms 
does not occur, the abdominal viscera are seldom enlarged, or only at 
a late stage, and the peculiar bone lesions are not met with. 

The prof/nosis is decidedly better than in inherited syphilis, and 
turns mainly on the condition of nutrition and the effects of treat- 
ment on it. 

In the treatment of syphilis in infants, whether inherited or ac- 
quire<l, but particularly in the former, the effects of mercury are 
most striking, especially the rapid and complete control which the 
drug has over the skin lesions of the early stage. It exercises 
also a very marked effect on the general nutrition, and under its use 
the ansemia diminishes rapidly. These beneficial results are, how^- 
ever, produced only after some months or more, and it is, therefore, 
necessary to continue the course of mercury for two months at least, 
and not to be induced by the disappearance of the rash to give up 
the remedy. When the first course is over the infant may be given 
tonics (the iodide of iron is specially recommended) for a month, 
and should then have another course of mercury for a month. This 
alternation should be practised three or four times, or till the end of 
eighteen months after the first manifestations. If symptoms appear 
later, the course should \ie re^x^ated again and again if necessary, and 
if the child can be watched, anaemia or any failure in nutrition, at 
eight or nine years or at puberty, should suggest the propriety of 
submitting it again to specific treatment, since it is at these ages that 
the later manifestations are specially prone to begin. In infants it is 
often best to resort to inunction. The mother should be instrufted tf) 
rub a scruple to half a drachm of blue ointment into the abdomen 
and back once or twice a day, and to cover the part with a soil hand- 
kerchief under the binder. In acfpn'red syphilis, or if the services 
of the mother cannf>t be ol)tained, the ointment may be spread on 
the handkerchief, over which the binder is then somewhat firmly 
applied. A flannel binder should not be applied directly over the 
surface treated with ointment, as this practice is apt to cause an 



20G SYPHILIS. 

amount of irritation of the skin which may render a suspension of 
the treatment necessary. Perchloride of mercury baths are the 
routine method of treatment adopted by some physicians. Baginsky, 
for example, states that since he began their use he has prescribed 
them in almost every case. The amount of mercury absorbed must 
be very small, but the treatment has the advantage that it disinfects 
the surface, and thus has a favorable influence on eruptions. A 
bath, which may be made by adding 1 pint of perchloride solution 
(1 in 1,000) to 3 J gals, water, should be given daily. For the inter- 
nal administration of mercury no preparation is more convenient and 
satisfoctory than gray powder ; 1 gr. may be given twice a day, and 
if the dose is Avell borne it should be gradually increased until the 
infant is taking 2 gr. twice a day. It may be combined with com- 
pound chalk powder if vomiting is produced, or it may be replaced 
by perchloride, gr. J-g- to -^-^ (liq. hydrarg. perchlor. (B. P.) n^^xv to 
xx) in flavored water thrice a day, or by calomel gr. -^^ twice a day. 
Mercury does not produce salivation in infants, in whom the functions 
of the salivary glands are very imperfectly established. It produces, 
however, after a time, diarrhoea, which should be an indication for 
stopping the drug for a time. In severe cases it may be desirable to 
give the drug both by inunction and internally. It is in such cases 
that hypodermic medication appears to be called for, but it is at- 
tended by considerable risk in very weakly children, and in stronger 
infants it is unnecessary to resort to a method of treatment which 
always causes a good deal of distress both to the patient and its 
guardians. 

Eruptions on the buttocks should be treated by strict attention to 
cleanliness, by the use of antiseptic powders (calomel 3ss to starch 
powder ,5j, with or without a little zinc powder). Wliite precipitate 
ointment (gr. xx to Sj) is a good application for sores about the face, or 
calomel cream (calomel 5j, olive oil oij, lanoline to Sj) which is also 
very useful as an application to rhagades. Obstinate local lesions 
may be treated with oleate of mercury, 1 to 2 per cent., or with the 
red oxide of mercury ointment applied frequently in small quantity 
with a camel-hair brush. Condylomata are best treated by dusting 
with calomel and great attention to cleanliness. Iodoform may be 
made to alternate, as a dusting powder, with calomel, but in any case 
tlie application should be made several times a day, and the parts 
thoroughly washed beforehand. 

The question of giving mercury to a mother suckling her syphilitic 
infant often arises. Chemical analysis of the milk has failed to 
reveal the presence of mercury, but very considerable improvement 
may follow in the infant on a course of mercury taken by its mother. 
This may be in part due to the improvement in her health due to the 
tonic action of the mercury, even in those cases in which she has not 



ii 



ACQUIRED SYPHILIS. 207 

been infected. If the mother presents any manifestations of sypliilis 
there can, of course, be not tlio least hesitation in treatiiiix her, but it 
is not wise to rely upon this for the treatment of the infant. It 
should receive mercury itself by the mouth or by inunction. 

Constant attention must be given to maintainino: the nutrition of 
the infant. If tlie mother's milk is available, it should b(> prescribed 
to the exclusion of all artificial foods. If tlie snutHiuir prevent suck- 
ling, the milk must be drawn off and given with a spoon. Atten- 
tion should be directed to the mother's digestion and general nutri- 
tion. Advantage will often be derived from giving her a tonic 
containing iron. If the child suffers from indigestion, small doses 
of pepsin or papain should be given after each feediug. 

Pseudo-paralysis should be treated by keeping the liml)s at rest, 
either by means of splints or by keeping the child on a pillow to 
which the limbs are secured by a broad l)andage. 

A child who has suffered from infantile syphilis should be care- 
fully reared, warmly clad, well fed, and watched so that it can be 
put under treatment at the first evidence of any late manifestations. 

In the treatment of late syphilis recourse must be had to iodides, 
either alone or alternately with short courses of mercury. The syrup 
of the iodide of iron is a useful remedy after pronounced symptoms 
have disappeared. 



CHAPTER XV. 
RHEUMATIC FEYER. 

Etiology — Symptoms — Endocarditis and Pericarditis — Subcutaneous Nodules — Rashes 
— Diagnosis — Prognosis — Cervical Rheumatism — Treatment. 

Rheumatic fever is a specific inflammatory process^ affecting 
mainly serous membranes and fibrous tissues, to which individuals 
who inherit a certain type of nervous organization are peculiarly 
prone. It is sporadic in most, if not all, countries, is most preva- 
lent in temperate climates in the spring, but presents epidemic in- 
creases at irregular intervals.^ 

Acute and subacute rheumatism present essentially the same fea- 
tures in children as in adults, but in them the affection of joints is 
often less marked and the disease less acute, though the liability to 
cardiac complications is probably greater. Under five years of age 
rheumatic fever is comparatively uncommon. It is more common 
between five and ten, but a larger number of first attacks occur 
during the second decade of life than in any other. Altogether, 
more than half the sufferers have their first attack before the age of 
twenty. 

The most potent predisposing cause is inheritance from father or 
mother of a tendency to rheumatism, and the liability is greater if 
both parents are rheumatic. 

The most frequent determining cause is chill, and its influence is 
increased by physical fatigue. 

The most important manifestations of rheumatism are arthritis, 
endocarditis, and pericarditis, subcutaneous nodules, and erythema. 
To this list chorea should probably be added. Its relation to 
rheumatism is discussed below. 

The characteristic affection of the joints in rheumatism is synovitis 
— acute or subacute — with serous effusion. There is injection of the 
synovial membrane, which may become covered with lymph. The 
fluid may be cloudy and contain shreds of fibrin, but the cellular 
element is scanty, only rarely giving the effusion a puriform appear- 
ance. The lesion of the pericardium is identical, but, owing to the 

^ According to Dr. Xewsholme, epidemics follow periods of deficient rainfall, and 
prevail when the subsoil water is low and the earth-temperature at 4 feet is high. _ In 
these respects rheumatic fever would resemble summer diarrhoea, which is certainly 
an infective disease. 

208 



i 



RHEUMATIC FEVER. 209 

constant movement, the lymph effused is thrown into folds, or into 
small elevations causing a general coarse roughening of tlie surface. 
In the pleura similar effusion of lymj^h on the surface takes place, 
but the fluid effuseil is especially liable to become purulent. 

The o;i.?f('/ of acute or subacute rheumatism is ffenerallv sudden. 
The child complains of chilliness, of stiffness, is indisjx>sed to move 
or eat, and perhaps vomits. The temperature is found to be ele- 
vated (101 "-103^ F.). The pain in the joints may be severe or, on 
the contrary, so slight that the child if in bed makes no complaint. 
There is, however, usually some tenderness, often very marked tender- 
ness, though there may be little reddening «if the skin and no fluid 
to Ix^ detected in the joint. The joints most often aftected are the 
ankles, wrists, and knees, in the oixier mentioned ; the hips and 
elbows more rarely. The metacarpal joints and the sheaths of the 
extensor tendons of the fingers appear to be more often affected than 
in adults. When the wrist joints and these tendons are simul- 
taneously attackeil the hand is kept in a rather characteristic attitude 
— the elbow is flexed, and the hand, slightly flexeil at wrist and at 
the metacarpo-phalangeal joint, is supix>rted by the other hand if it 
be unaffected, and carefully guarded from any jar or rough contact. 
As a rule, not more than one or two joints are attacked simul- 
taneously, though many joints may be successively attacked. In a 
well-marked acute attack with high temperature, free i>erspiration 
having an acid odor is the rule, but in the less acute cases the sweating 
may not be very marked nor the odor noticeable. The very copious 
>weat5 so frecpient in adults are certainly less common in children. 

The most important characteristic of acute rheumatism in early 
life is the frequency with which the heart and pericardium are in- 
volveil. As has l)een said, the pericardium in children behaves like 
a joint, and it may l>e the only joint, or at least the fii*st joint at- 
tacked. In such cases the symptoms are far from characteristic. 
I The child looks ill, has slight elevation of temperature, and if it 
I complain of pain at all refers it to the pnecordia or epigastrium. The 
diagnosis must then dej)end mainly on the recognition of the physical 
I signs of pericarditis, whicli are discussed in another place. Endo- 
; carditis may develop independently of pericarditis, and even more 
, insidiously, since there may l>e al^solutely no pain. The onset can 
only be discovered by physical examination of the heart, which 
should be performed in every case in which rheumatism is suspected, 
j It should be repeated systematically so long as the tem]>erature re- 
' mains elevated. The heart is affected in about three-fourths ' of all 

' * Donkin found either old or active heart disea.** in sixty-one out of seventy 

' CMes, aped four to fourteen — i', f., 87 per cent. Church {St. B<irt\ Rrp(*., vol. xxiii., 

, p. 273] found cardiac affections in 83 per cent, of his case* under ten yeani, and 69 

f per cent, in the next decade ; but the number of cases under ten wa« gmall. 

14 



210 RHEUMATIC FEVEB. 

the cases of acute rheumatism under fifteen. Pleurisy with effusion 
is a not uncommon complication, and in a few cases is the initial lesion. 
Dry pleurisy is a common malady in children who have suffered 
from acute or subacute rheumatism. Whether any large proportion 
of the cases of dry pleurisy or of pleurisy with effusion in children 
who have not suffered from rheumatism are rheumatic must remain 
doubtful ; many are relieved but not cured by salicylates, in very 
much the same way as rheumatic arthritis. Acute tonsillitis may 
precede an attack of acute rheumatism ; less often it comes on during 
its course, or as it is passing away. Rheumatic children are very 
liable to repeated attacks of acute tonsillitis ; and it seems probable 
that some of those attacks frequently encountered in children who 
have not suffered from rheumatism are rheumatic in nature. Pneu- 
monia is a not uncommon complication of rheumatism in children, 
but is probably so far accidental that it is not due directly to the 
rheumatic process. Rheumatic affections of the muscles may be the 
most pronounced feature of an attack, but, if they occur during the 
course of acute rheumatism, do not produce marked symptoms, ow- 
ing to the child being bedridden. Rheumatism of the sternomastoid 
may cause torticollis, and rheumatism of the abdominal muscles 
acute abdominal pains and tenderness so severe as to simulate peri- 
tonitis. 

Subcutaneous nodules are an interesting form of rheumatic in- 
flammation of the fibrous tissues. They are of considerable diag- 
nostic importance, since they may be present in obscure rheumatic 
affection of the heart, even when the joints are not obviously in- 
volved. Usually, however, when they are present the joints are 
affected. They are said by Coutts^ to be discoverable in 20 per cent, 
of all cases of acute rheumatism with heart disease in children. 
When they are associated with heart disease the cardiac affection is 
often severe and progressive. Though they may appear during a 
period of pyrexia, their development does not seem necessarily to be 
attended by fever. In size they vary from a mass barely percep- 
tible to the touch to that of an almond ; but usually they are not 
larger than a melon seed. They are movable under the skin. There 
may be few or many. They develop rapidly, sometimes appearing 
in successive crops, and may disappear in a week or ten days, which 
is rare, or persist for several months. They are little, if at all, ten- 
der. They occur usually about the joints, especially the elbows, the 
knuckles, the malleoli, at the edge of the patella, and sometimes over 
the vertebral spines, the scapulae, the iliac crest, and the occiput. It 
is possible that similar nodules may be produced by syphilis, but 
with this exception, if it be one, they are found only as a rheumatic 
manifestation. 

^Donkins's "Diseases of Childhood (Medical)," London, 1893, p. 213. 



SUBCUTASEOrS SODULES. 211 

Various rashes may be observed. Sudamina are vcrv ooiiimon, 
and a line red rash resemblinir the early stage of the searhitina ex- 
anthem is not uncommon. Erythema, of various forms, mav accom- 
pany, precede, or follow the arthritic attacks. Urticaria occurs oc- 
casionally. Purpura sometimes ensues on intense erythema, but it 
may develop rapidly during acute rheumatism, and may be attended 
by hiematuria. 

En/ihcma nodosinn is certainly more common in rlieumatic children 
than in others, though some authorities doubt whether in truth it is 
a rheumatic affection. After a fever articular pains in the lower 
limbs and general malaise have existed for several days, oval sym- 
metrical swellings appear over the tibia\ They are of a bright red 
color and tender ; their long diameter, which is verticid, measures 
from 1 to 2 or 3 inches. After a day or two the swelling, at first 
tense, becomes soft and of a dusky hue. The color then passes 
through the stages usual in a bruise, and the lesion disappears in eight 
or nine days. There may be several symmetrical swellings over the 
tibiae, or successive crops may come out. More rarely, erythema 
nodosum appears on the outer side of the leg or on the arms. The 
attack is not always accompanied by arthritis, but, on the other hand, 
in some of these non-arthritic cases endocarditis ensues. Taking all 
cases of erythema nodosum, it is found that acute or subacute arthritis 
or cardiac lesion occurs in the majority, and that in some of the 
minority there is a family history of rheumatism. 

The general symptoms of rheumatism vary very greatly in intensity, 
and are in proportion, as a rule, to the amount of fever. The child 
feels and looks ill, and even when there is little or no pain is disin- 
clined to move. The lx)wels are constipated at first, food is refused, 
but drink eagerly swallowed. The temperature presents great vari- 
ations, but is, on the whole, lower than in adults. In an ordinary 
attack it will range between 101° and 103° F., in subacute cases it 
may not rise much above 100° F., and serious cardiac lesions may 
be prfKluced M*ithout any observed elevation of temjx'rature. 

Hyperpyrexia is rare in children.^ The symptoms are a sudden 
rise of temperature to 10G°-110° F., delirium or coma, headache, 
pain in the back, twitching of the face and fingers, and hurried 
respiration and pulse. These symptoms were formerly attributed to 
meningitis. As a matter of fact, meningitis, whether cerebral or 
spinal, is not, it would appear, produced by the rheumatic poison. 

The blood is rapidly and seriously affected in acute rheumatism. 
There is marked leucocytosis, and a profound degree of anjemia may 

'The report of the C'ommittee of the Clinical Society on Hyperpyrexia ( Trntui- 
fkdionji, vol. XV., p. 26o ) dealt with 1,300 cane^ of rheumatism, but only 1.8 per cent, 
were under ten years. None of them suffere^l from hy|)erpyrexia. In the next dec- 
ade, however (ten to twenty), there were a larger number of cases (34.6 per cent. ), 
bot they yielded only 10.4 per cent, of the hyperpyrexial cases. 



212 RHEUMATIC FEVER. 

be brought about very quickly. The rapid formation of a fibrinous 
clot in the right ventricle or pulmonary artery is an occasional cause 
of a sudden fotal termination during the course of an acute attack, 
or even after convalescence has, apparently, become established. 
Subacute rheumatism also may entail extreme anaemia, and the 
characteristic appearance which patients who are liable to attacks of 
subacute rheumatism present is due to this cause, though in addition 
the skin has a slight waxy or sub-icteric tint. 

The diagnosis of rheumatism, whether acute or subacute, if it in- 
volve the joints is commonly not difficult if the case can be observed 
for a few days. In the first place, rheumatism is the most common 
cause of acute arthritis in children, and the subsidence of inflamma- 
tion in one joint with its appearance in another is extremely charac- 
teristic. Multiple arthritis secondary to exanthematous diseases 
(q. V.) is seldom so acute or so Avell-marked as to lead to error, though 
in the absence of a history some difficulty may arise. In this con- 
nection diphtheria must be thought of, since pains in and about the 
joints are of not uncommon occurrence in that disease, and the local 
affection may be so mild as to provoke no marked symptoms referable 
to the throat. The arthritis secondary to gonorrhoea is exceedingly 
rare in children. Pysemic arthritis from other causes is also rare, 
but may simulate acute rheumatic arthritis very nearly ; the local 
inflammation and reddening of the skin is greater, subsidence in 
the joints first affected is, as a rule, less rapid and complete, and the 
temperature will commonly show marked pysemic characters. In 
the absence of distinct evidence of a source of pysemic infection, 
the diagnosis is difficult and is probably seldom made in the early 
stage. The possibility that the arthritis is due to acute epiphysitis 
(q. V.) must also be borne in mind, especially in young children and 
infants. 

Sanguineous effusion into the joints in haemophilia may be at- 
tended with pain and some general disturbance, so that in the ab- 
sence of a definite history some hesitation may be felt at first. The 
pain, however, is slight, compared with that attending rheumatic 
synovitis which has produced like distension of the joint, and in a 
few days the true nature of the case will be made clear. Scurvy- 
rickets is hardly likely to be confounded with rheumatism if the 
ages at which the two affections occur are borne in mind, more es- 
pecially as the tender swellings produced in scurvy are often seated 
over the long bones, or, if in relation with the joints, do not cause 
effusion into them in the early stage. In like manner a careful 
physical examination, and a consideration of the age and the sur- 
rounding circumstances of the patient, will prevent the tenderness 
and epiphysial swelling of acute rickets from being supposed to be 
rheumatic synovitis. It should be remembered that infantile paraly- 



i 



CERVICAL EHEC^rATIS^L 213 

sis may be accompanied at its onset by flying pains in the limbs and 
bv some tenderness of the joints, especially of the atfeeted limb. 

[We wonld emphasize the importance of the c<Miception of rheuma- 
tism in children as set forth bv Cheadle and other Eno:lish writers. 
Unless we realize and accept this conception of the disease, it will 
often escai>e ns. If we look, in children, only for the clinical picture 
as seen in adults, the sudden onset witii liigh temperature, marked 
joint symptoms and acid sweats, we shall rarely find rheumatism. 
This picture is seldom seen. AVe must look for other and more 
varied manifestations, occurring more irregularly, not grouped within 
a few weeks or months but extending over a ])criod, it may be of 
years. Especially must we be on tlie lookout for endo- and peri- 
carditis ; one is rarely present without the other in the rheumatic 
heart affections of children. These are much more common than the 
joint symptoms. " Endocarditis is at its maximum, arthritis at its 
minimum." 

The occurrence of the subcutaneous fibrous nodules is not as com- 
mon in America as it apparently is in England. But two cases pre- 
senting these nodules have been seen in seven years' experience with 
two large Chicago clinics. AVith a child who has had, at any time 
in his life, attacks of tonsillitis, or of erythema, or of bronchitis, 
who gives a history of indefinite joint pains, or in whom subcutaneous 
nodules have been noted, who in any way presents one or more of the 
manifestations of rheumatism, the heart must be watched most care- 
fully with the recognition that these apparently widely different 
phenomena are in reality closely related, and but symptoms of a 
single underlying diathesis.] 

The prognosis of acute rheumatism is in cliildren somewhat better 

than in adults, so far as recovery from the acute attack is concerned. 

Death is brought about most often by pleurisy or pneumonia, rarely 

by |x?ricarditis or endocarditis, at least in a first attack. If the heart 

has been damaged by previous attacks, death may be caused by 

^ cardiac failure. On the other hand, a favorable prognosis as to the 

remoter future must be given witli the utmost caution, even in cases 

^ of subacute rheumatism. The great frequency with which the heart 

" is involved in children has already been mentioned, and there is no 

doubt that a child who has once suffered from rlieumatism, acute or 

I subacute, is extremely liable to fresh attacks, during one of which the 

heart is very likely to iKi involved. 

Cervical rheumatism is a manifestation of rheumatism sufficiently 
I cf»mmon in children, and sufficiently characteristic to deserve special 
' mention. The rheumatic process may attack the articulations of the 
^ cervical vertebne, their lig-aments, or the muscles. The child is 
seized sudrlenly by severe pain in the neck, which is held rigidly. 
1 There is tenrlerness along the spine. Frequently, owing either to 



214 RHEUMATIC FEVER. 

simultaneous affection of the muscles or to their contraction to pro- 
tect the painful part, there is torticollis, or retraction of the head. 
The pain is very much increased by any movement of the head. The 
attack may be the initial symptom of acute rheumatism which sub- 
sequently runs an ordinary course, or it may occur as an isolated 
phenomenon. Occasionally it is complicated by endocarditis or peri- 
carditis. The course of the affection is usually subacute, and recov- 
ery ensues ; but in some cases chronic arthritis or fibrous thickening 
of the ligaments and muscles remains, producing lasting rigidity or 
distortion of the neck. The only difficulty in diagnosis is to distin- 
guish the affection from tuberculous osteitis of the cervical vertebrae ; 
the sudden onset and the severity of the symptoms at an early stage 
will generally prevent error, and as a rule the effect of treatment by 
sodium salicylate will remove any uncertainty. In many cases, how- 
ever, this drug, though it leads to improvement, fails to effect a cure, 
and in such cases careful massage of the parts is to be recommended. 
Recovery may often be hastened by mild counter-irritation. 

The treatment of acute rheumatism in childhood must follow the 
same lines as in adults. The patient should be put to bed in a flan- 
nel nightgown between blankets or flannel sheets. The joints should 
be enveloped in cotton-wool, and a cotton-wool or flannel pad lightly 
but firmly bandaged over the chest by a many-tailed bandage. 
Great relief may be obtained by the application of suitable splints 
when the knees, elbows, or wrists are involved. Local applications 
may be tried if the pain be severe — chloroform liniment, aconite 
liniment, or the chloroformum aconiti, B.P.C. Osier recommends 
hot cloths saturated with Fuller's lotion (see Appendix). 

[Carbonate Sodium, 5vj 

Laudanum, gj 

Glycerine, gij 

Water, gix] 

In Germany cold compresses or ice-bags are much used. Small 
blisters above and below the joint, or, in the case of the knee, along 
the outer and inner sides of the patella, are valuable means of reliev- 
ing pain in subacute cases, but are not to be recommended in acute 
attacks or in young children. When the ankles or wrists and fingers 
alone are involved relief may be obtained by local hot baths at about 
100° F.^ They should be repeated two or three times a day, the 
parts well dried and then wrapped in cotton-wool. 

Of internal remedies the salicylates take the first place. Under 
their influence the pain is nearly always relieved if not entirely re- 
moved, and although they do not prevent heart complications, they 

1 Lenhartz (Penzoldt and Stintzing's '^Handbuch," Bd. v. ,s, 159) recommends 
the addition of common salt, I to 1 lb. in a wash-handbasin of water. 



I 



CERVICAL RHEUMATISM. 215 

perhaps render the attack shorter, and certainly easier to bo borne. 
In a disease which tends to produce exhaustion this is an advantage 
not lightly to be set aside. 

The amount of sodium salicylate which may be given to a child 
five or six years old, during the first two or three days, may be set 
down at GO to 80 grains. It should be given in divided doses every 
two or three hours, day and night. 

[Sotlii Salicvlatis, 3.1 Scniii Salicyl. , 3J~3U 

Tn. Aunintii Rec., Liq. Amnion. Aeetat., 

Glycerini, fifi 3ii ^.^t. Aurantii, fid 5JU 

Aq., ad 5j' Aq., ad 5,1' 

Dose — 3J every 2 or 3 hours. Dose — 3i t-very 2 or 3 hours. 

Appendix.] 

As the pain subsides the daily quantity should be reduced, but the 
smaller doses should still be given at frequent intervals. This 
seems to be important, since the drug is rapidly eliminated. 
Salol, which is decomposed by the alkaline intestinal secre- 
tions into siilicylic acid and phenol, yielding about 60 per cent, 
of the former, has been recommended, partly with the object of 
insuring the continuous absorption of a salicylate. It may be given 
in jx>wder. Salophen, which under similar conditions yields 51 per 
cent, of salicylic acid, has been preferred when it is desired to keep 
up the action of salicylic acid for long periods, since it is less poison- 
ous and more slowly decomposed than salol. Salicin does not appear 
to have any advantage over salicylate of sodium, and has the disad- 
vantage of being less soluble. The dose for a child of six is about 
gr. iij every three or four hours. That the salicyl compounds do 
not prevent the heart being attacked is admitted, and it has been as- 
serted that, so far from preventing, they rather favor relapses. On 
the other hand, it is held by some, as I believe correctly, that this 
opinion is due to the practice of stopping the drug so soon as the 
joint pains have been relieved. This view is maintained especially 
by French physicians.' Jules Simon begins with a small dose, h 
gramme (1\ grains) on the first day, and increases it by I gramme 
a day until the maximum dose, for a child of ten, of 3 grannnes (4-") 
grains) is reached. He then l^egins to reduce it by 15 grains 
daily until the child is taking only 15 grains a day; this dose is 
continue^l for a week at least. The whole period (jf treatment occu- 
pies a nu»nth or more, and the child is kept in ImmI for that period 
whether it present rheumatic pains or not. 

In some few cases the .salicylic compounds appear to exercise no 
influence over the disease, and in other cases, rarer in children than 
in adults, they produce toxic symptoms, delirium, vomiting, epistaxis, 

'Seethe " Year-Book of Treatment " for 1895, p. 194; 1890, p. 101. 



216 RHEUMATIC FEVER. 

intestinal haemorrhage, dyspnoea, or great cardiac weakness.^ When 
the remedy has to be stopped for one of these reasons, the best alterna- 
tive treatment is the alkaline. It is founded on the theory that the 
symptoms of rhumatism are due to an excessive production of acid 
(it is said, lactic acid). The object aimed at is to render the urine 
alkaline. The drawback to the treatment, which undoubtedly re- 
lieves the joint pains and, it is said, diminishes the liability to cardiac 
complications, is that it has a very depressing effect, and increases 
the tendency to anaemia. It is worse than useless to give insufficient 
doses of alkali for a long period. The dose should be regulated so 
as to render the urine alkaline ; at least 30 to 40 grains must be 
given to a child of ten every three or four hours. It may be com- 
bined with potassium acetate, as advised by Fuller (see Appendix). 

[Sodii Bicarbon., gr. xxx to xl 

Potassii Acetatis, gr. x 

Aq., 5ss 

In effervescence witli citric acid (gr. x) or fresh lemon juice (5Jss) every 4 hours, 
to be reduced after 24 hours.] 

The desired effect on the urine should be obtained within twenty- 
four hours, and the amount of alkali then diminished but maintained 
at such a quantity as wdll just keep the urine alkaline. Quinine may 
be combined with the alkali to diminish the depressing effect. 

[Quinine and Alkali (Garrod). 
Quininse Sulph., gr. ij 

Potassii Bicarb. , gr. xx 

Tn. Aurantii, "ITL^iJ 

Mucil. Acac, 5ss 

Aq., ad 3ij 

(A single dose. ) The quinine is rubbed up with the bicarbonate, dissolved in 
water and the mucilage added afterwards. Appendix. ] 

When the joint pains are severe, small doses of opium (by preference, 
perhaps, Dover's powder, gr. v to a child of ten) may be given on the 
first night; but it will seldom be necessary to repeat the dose, if salicy- 
late can be taken. The use of opium, absolute rest in bed in a darkened 
room, and cotton-wool wTaps to the joints were the main points in 
the so-called " expectant treatment '^ of Gull and Sutton.^ 

An alkali is by some physicians combined with sodium salicylate 
in the treatment of both acute and subacute rheumatism. 

' I am not aware of any instance in which it has produced albuminuria in a child. 
Probably the toxic symptoms are not infrequently due to impurities in the "artificial" 
salicylate. The "natural" product is therefore to be preferred. 

^See the admirable article in Fagge and Pye-Smith's " Medicine," vol. ii., p. 702, 
3d edit. The whole article deserves careful perusal. The dose of opium was, for an 
adult, 1 grain nightly, or oftener if pain were severe. 



CERVICAL RHEUMATISM. 217 

[Sodii Salicylatis, 

Sodii Bicarbonatis, aa jtJss 

Tn. Aurantii Kec., 

Give, fui 5iij 

Aq., ad 5i.j 

Dose — 5ii every 3 or 4 liours. Appendix,] 

But this lino of treatment, if it be recommended at all, seems better 
adapted to subacute recurrent attacks. Such attacks are oft<in little 
amenable to the salicylate treatment, and when rheumatic cachexia 
>\'ith marked auivmia has become established, it should not be resorted 
to. In such cases iron should be given in the form of the solution of 
the perchloride, or, if that drug produce gastric disturbance and diar- 
rhoea, as is sometimes the case, it may be replaced by the citrate of 
iron and ammonia (gr. v thrice daily to a child of eight). When 
stiffness, aching, or flying pains in the joints are troublesome, the 
addition of 3 to 5 grains of sodium salicylate to each dose of citrate 
sometimes relieves ; but tincture of colchicum in doses of TTLx to xv 
thrice a day (for a child of ten) will commonly be found a more ef- 
fective remedy. With the colchicum may be combined small doses 
of potassium iodide (gr. v thrice daily for a child of ten), and the col- 
chicum should after a few days be replaced in this combination by a 
grain of quinine. Drugs, however, with the exception, perhaps, of 
iron, commonly fail to exercise any conspicuous effect, and the 
greater reliance must be placed on attention to diet and clothing. 



CHAPTER XVI. 
CHRONIC RHEUMATIC AFFECTIONS. 

The Rheumatic Cachexia, and Chronic Rheumatism — Rheumatoid Arthritis. 

The nomenclature of diseases enumerates in succession in the list of 
general diseases : — Rheumatic fever (acute rheumatism), rheumatism 
(subacute and chronic rheumatism), gout, and osteo-arthritis (rheu- 
matoid arthritis). To these must be added the various forms of 
arthritis, especially polyarthritis, which occur as complications of acute 
infectious diseases, and chorea, which has certainly intimate relations 
with rheumatism. The group is a somewhat miscellaneous assem- 
blage, but the arrangement is convenient from the clinical point of 
view, since it brings into relation morbid states which must in some 
cases be compared and in others contrasted. 

Rheumatic Cachexia. — A child which has once suffered from 
acute or subacute rheumatism is, as had already been said, very liable 
to suffer renewed attacks ; and children who have had chorea are 
likewise peculiarly liable to suffer from recurrent attacks of rheuma- 
tism. Children who present the rheumatic diathesis to a well- 
marked degree, even though they have never had an attack of defi- 
nite rheumatism, are very apt to pass into a condition of debility 
characterized by ansemia and recurrent rheumatic pains in the joints 
and muscles, with, perhaps, frequent tonsillitis. To this condition 
the term rheumatic cachexia may justly be applied. It occurs chiefly 
in girls shortly before menstruation, and in boys a few years before 
puberty. The child often grows quickly, ^^ outgrows its strength," 
as it is said. Its appetite is capricious ; it is very easily fatigued, 
and slight exposure, if combined with fatigue, is almost certain to be 
followed by sore throat (tonsillitis) or rheumatic pains, or by sub- 
acute or acute rheumatism. Even if an acute attack be escaped, it 
is rare for the heart not to be affected sooner or later, and it is cases 
of this type, which yield, I believe, the larger proportion of the cases 
of malignant endocarditis. It is to such cases that the term chronic 
rheumatism is most properly applied ; but the term has been so much 
abused that it is better to avoid it, more especially as such children 
are, as has been said, very liable to acute or subacute attacks. 

Change of air, often regarded as a panacea for all conditions of 
chronic ill-health, little avails the sufferers from the rheumatic 

218 



RHEUMATOID ARTHRITIS. 219 

cachexia. They often experience tlieir most serions attacks on re- 
turning to a town after a country lioliday. When the ph\ee of resi- 
dence can be selected, the warm reh\xing climates sometimes chosen 
should be avoided. A dry inland place on high ground away from 
river or lakes, and with few wet days, probably offers the best pros- 
pect for these patients, owing mainly, no doubt, to the fact that in 
such localities they are able to get out of doors on mosi days of 
the year. Neither the seaside nor mountainous districts suit them. 
Attention should be directed to the sanitary arrangements of the house, 
its warming, lighting, and drainage. Contamination of the air of the 
house by emanations from sewers certainly produces a deteriorati(^n 
of the general lundth, and not improbably has an even more direct 
influence in determining tonsillitis and other rheumatic manifestations. 

Rheumatoid arthritis (arthritis deformans, osteo-arthritis) occurs 
in childhood somewhat more frequently than aj^pears to be generally 
recognized. Following Charcot's division of the cases of this dis- 
order into (a) Heberden's nodes ; (6) the general, progressive poly- 
arthritic form ; and (c) the monarthritic form, it may be said that 
the last is extremely rare, if indeed it ever occurs in childhood.* 

Hcberdax's nodes, small nodules which form generally at the distal 
extremity of the second phalanges of one or more fingers, arc not 
very uncommon. Their appearance, or increase in size, is some- 
times accompanied by pain, redness and swelling of the joints of the 
fingers ; this passes away, leaving the nodules in a condition of qui- 
escence unattended by pain, except when the part is knocked. 

Progressive polyarthritis deformans commonly develops in chil- 
dren in a manner which certainly presents considerable clinical 
resemblance to a mild attack of rheumatic fever, although the path- 
ology is probably different. There is some elevation of temperature, 
pain, tenderness, and swelling ; sometimes redness of several, often 
of uiiiny joints. The symptoms are little, if at all, controlled by 
salicylates, but subside in a few days ; another attack occurs after a 
short interval, and after a time it is perceived that the ends of the 
bones are enlarged, and the movements of the articulations limited. 
The form of the joints becomes gradually distorted, owing in part to 
the formation of osteophytes, and in part to thickening of the liga- 
ments. The synovial cartilages disappear, and are replaced by an 
ivory-like thickening of the ends of the bones. The muscles mov- 
ing the affected joints become atrophied to a greater or less degree, 
and the hands, wrist, and limbs assume various abnormal positions. 
The course of the disease is, on the whole, progressive ; but af\er 
the subacute exacerbations considerable improvement may occur, and 
the disi*ase may remain quiescent for years. 

'Marfan, "Traits des Mai. de I'Enf." (Grancher, roml)y, et Marfan j denies 
that it occur*, and I have never seen a ca«e. 



220 CHRONIC RHEUMATIC AFFECTIONS. 

In some cases the distribution both of the osseous and articular 
lesions and of the muscular atrophy is remarkably symmetrical, but 
" glossy skin/' and other skin changes are at least uncommon in 
children. 

The etiology is obscure. In the most typical cases the distribu- 
tion of the lesions undoubtedly suggests a central nervous origin, 
and mental anxiety and other depressing emotions sometimes appear 
to be determining causes of an attack or exacerbation in children 
as in adults. In some cases there is a family history of joint af- 
fections commonly described as rheumatic. The disease is very un- 
common under five years, rare under ten. The symptoms are ag- 
gravated by exposure to cold and damp. It is usually taught that 
the condition has no relation to rheumatism. Even acute rheuma- 
tism is, however, held by many to be due to a primary affection of 
the nervous centres, and there are cases of chronic rheumatism so- 
called, with heart lesion, which in other respects present a general 
resemblance to the polyarthritic form of rheumatoid arthritis. The 
diagnosis is, therefore, sometimes difficult, especially in children who 
have suffered from several febrile attacks with joint pains, attacks al- 
ways spoken of by parents as rheumatic fever or rheumatism. In well- 
established cases in which the characteristic deformities about the 
joints and atrophy of muscles exist, the diagnosis is usually easy. 
Periosteal nodes, a rare complication of acute or subacute rheuma- 
tism, may give rise to a superficial resemblance, but the nodes, as a 
rule, disappear rapidly under salicylates. 

The treatment during the exacerbations should consist of rest in 
bed, careful dieting, and soothing applications to the joints, which 
should be wrapped in cotton-wool. Salicylates do not, as a rule, 
exercise any influence. In the intervals the general nutrition should 
be improved by every available means, including careful dieting, 
warm clothing, and change of air at suitable times. Cod-liver oil 
and malt, the milder preparations of iron, and arsenic are valuable 
adjuvants, and advantage is often derived from strychnine in doses 
as full as can be borne. Galvanism yields good results in some cases. 
One pole should be placed in a basin of salted Avater, while the other 
electrode is placed on the spine over the cervical or lumbar enlarge- 
ment, as the case may be. The hands or feet are then placed in the 
basin, and the current passed at first with the lower pole negative, 
and subsequently reversed. 



II 



CHAPTEE XVII. 
INFECTIVE ARTHRITIS. 

Polyarthritis and ^[onarthritis — Scarlet Fever — Diphtheria — Typhoid Fever — 
Mumps — Gonorrhcea — Acute Epiphysitis — Prophylaxis and Treatment of In- 
fective Arthritis. 

Not only gonorrhcea, and other purulent infections, but also scarlet 
fever, typhoid fever, cholera, mumps, diphtlieria, ervsijielas and 
other specific infectious fevers may be complicated by arthritis. The 
arthritis may be due either to the action of the si>ecific infection or to 
a secondary' infection by pyococci. In the former alternative the 
smaller joints are those most often affected, many being attacked 
simultaneously or in rapid succession. The affection is a polyarthritis, 
and thus resembles acute rheumatism ; but it is commonly mild and 
transitory. In the latter, on the contrary, the large joints are those 
usually affected, and the inflammation is often limited to one, but it 
may be so severe as to cause more or less complete disorganization 
of the articulation attacked. 

Polyarthritis is a rare complication of any of the infectious fevers. 
Scarlet fever is held to be that most often thus complicated. This 
opinion is ])erhaps due to the fact that the arthritis which occurs as 
a compliciUion of scarlet fever is commonly more severe than that 
observed in other fevers, and that it is sometimes attended by endo- 
carditis. 

In those cases in which many joints are attacked in succession, all 
the structures of the articulation affected are involved ; but there 
may or may not be sufficient effusion to distend the joint. The 
effusion is serous, and in some cases there is teno-synovitis. The 
symptoms are usually characteristic — pain in the joint increased by 
movement, tenderness, more or less reddening of the skin, and 
swelling of the joint. The pain and tenderness are less severe than 
in acute rheumatism, and the whole affection is milder. 

Aiihritia due to pyococcal infection appears to commence as a ca- 
tarrhal synovitis, but at an earlv stage the cartilages and ligaments 
are involved, and the effusion becomes sero-purulent, or purulent. 
The affected joint is painful and tender, and the skin hot and red. 
The course of the arthritis varies ; in some, perhaps the majority of 
cases, the symptoms subside rapidly, and the functions of the joint 

221 



222 INFECTIVE ARTHRITIS. 

are restored. In others ankylosis ensues with atrophy of the muscles 
about the joint. AVhen suppuration occurs, and separation of the 
epiphyses, dislocation may ensue, with more or less complete disor- 
ganization of the joint. In such cases there is a general infection, 
often of distinctly pysemic type. 

Polyarthritis when it occurs as a" complication oi scarlet fever comes 
on usually rather late ; that is, during the third week after the onset 
of the disease. It is believed to be less frequent in children than in 
adults. It affects by preference the smaller joints, those of the 
hand, wrist, and foot, less often the ankle, sometimes those of the 
cervical vertebrae, producing retraction of the head or flexion on one 
or other shoulder. The joints are not much swollen, the skin is little 
reddened, the pain is not severe. As a rule recovery is rapid and 
complete, but occasionally ankylosis occurs. Suppurative arthritis is 
a rare complication of scarlet fever : it occurs almost exclusively in 
severe cases presenting other pysemic symptoms ; it is generally lim- 
ited to one, or to few joints. 

Arthritis is an occasional complication of diphtheria ; it comes on 
usually in the second or third week, and the articulations most often 
affected are the knees and other large joints. Pain is usually out of 
proportion to the visible swelling or other evidence of inflammation. 
Suppurative arthritis due to secondary infection is a rare accident. 
Mild attacks are perhaps rather more common in cases treated by the 
antitoxic serum than in others. 

Arthritis affecting usually many joints to a varying but, in most 
instances, slight degree, is a rare complication of typhoid fever. It is 
observed in the second or third week. Even in the absence of much 
or any swelling of the joint, pain may be severe, but is usually of 
short duration. Another form of arthritis occurs at a later date ; it 
is usually limited to one joint, generally the hip, and occasionally 
results in ankylosis or dislocation. In some cases, apparently rheu- 
matic, the lesion is in reality due to osteo-myelitis, attended by 
effusion, which may be purulent, into the joint. In other cases the 
osteo-myelitis is of a more chronic type, and may lead to the for- 
mation of exostoses. ^^ Typhoid spine,^' a condition in which all 
movements of the spine are painful, is occasionally met with in 
children. 

Mumps is in very rare instances complicated by arthritis or teno- 
synovitis of mild type and short duration. In certain epidemics of 
cerebrospinal meningitis polyarthritis is observed in a large proportion 
of cases. 

Gonorrhoeal arthritis may occur in children, especially girls, in 
whom gonorrhoeal vulvo-vaginitis is not very uncommon ; it has also 
occurred as a complication of gonorrhoeal ophthalmia in new-born 
children. The onset of the arthritis is attended by general febrile 



GOSORJRHCEAL ARTHRITIS. 223 

symptoms, and as they subside it is found tliat one or more jointe 
are hot, swollen, and painful. The joint most often attacked is the 
knee ; then the wrist, ankle, the small joints of the hands and foot, 
least often the hip-joint. As a rule eomplete recovery takes place, 
even though the fluid eflused into the joint has been purulent, but 
obvious improvement may not be observable for several weeks. An 
occasional complication is atrophy of the nuiscles about the affected 
ioint. 

Acute epiphi/sitiSf that is to say, acute osteitis of the epiphysis or 
of the diaphysis near the growing line is a not uncommon affection 
in young children. It produces acute local i)ain and tenderness, and 
fever of varying intensity. It attacks most often the hip, elbow, 
shoulder, and ankle, and is commonly limited to one joint. In acute 
cases the intensity of the local process, and the fact that the swelling 
in the early stage is distinctly away from the joint (except in the 
hip) will assist the diagnosis from acute rheumatism,. but mistakes 
have been made by the most skilful. A form of this affection which 
occurs in infants has been specially described under the name Acute 
Epiphi/sith (or Arthritis) of Infants. Most of the cases occur in in- 
fants under one year, and may develop a few days after birth. The 
acute inflammation at or near the ossifying centre leads to necrosis 
and suppuration. The abscess, in most cases, opens into the joint, 
and produces an acute arthritis attended by much local swelling, 
tenderness, and reddening of the skin. After a few days of fretful- 
ness it is noticed that the infant does not move the limb, and that 
passive movement causes acute pain. The hip is most often at- 
tacked, and next the knee. Other joints may also become inflamed, 
and the condition of those earliest attacked may improve, but after a 
short time the more serious affection of one joint becomes evident. 
The disease is certainly pya?mic, and the secondary affection of other 
joints, when not due to direct extension of the osteo-myelitis, is of 
this nature. The prognosis is extremely bad, nearly half the cases 
dying of pyremia. AVhenever there is reason to suspect this condi- 
tion the limb should be kept at rest by bandaging it to a splint, or 
in ver\' young infants by bandaging the child to a pillow so as to 
prevent movement of the affected limb. Owing to the fact that 
rheumatism is extremely rare in infants, if indeed it ever occur, a 
mistake in diagnosis, in spite of the great resemblance l>ctwcen the 
two diseases in an early stage, is little likely to be made. It is safer to 
assume that a case of multiple arthritis, or of multiple inflammatory 
affection about the joints in infants is })yfemic, and to watch for the 
earliest indications which may point to the formation of pus in the 
neighV>orhof)d of the joint, or of infusion into it. Pearly incision and 
drainage appears to hold out the best prosiKJct of recovery in cases in 
which the disease makes progress in spite of keeping the limbs at rest. 



224 INFECTIVE ARTHRITIS. 

Prophylaxis. — The occurrence of secondary arthritis in so many 
forms of acute infectious disease is an additional proof of the im- 
portance of the prevention or early treatment of all suppurative com- 
plications such as those occurring in the mouth, throat, ear, con- 
junctivae, or vulva. The treatment of purulent arthritis must be 
conducted on general surgical principles, but it is desirable that the 
joint should not be kept immobile longer than is necessary to relieve 
pain, and that if wasting of muscles occur massage and galvanization 
should be resorted to at an early date. In those forms of secondary 
arthritis which occur earlier in the course of the specific infection, 
by which probably they are, at least in some cases, directly pro- 
duced, the ordinary treatment of rheumatism has little influence. 
Sodium salicylate has not the marked effect customarily observed in 
true acute articular rheumatism. It does, however, exercise some 
influence and may be used in combination with antipyrin, or these 
drugs may be replaced by quinine in cases in which a depressing ef- 
fect is to be feared from antipyrin. The patient should be kept in 
bed and the affected part wrapped in cotton-wool. 

In gonorrhoeal arthritis the most effective means should be at 
once taken for the cure of the local infection, and they should be 
persevered in so long as there is any evidence of local inflammation 
(vulvitis, conjunctivitis). 



CHAPTER XV III. 
CHOREA. 

General Characters — Etiology — Pathology — Svmptoms — Recurrence — Treatment. 

^ CHOREA MINOR (ST. VITUS'S DANCE). 

St. Virus's Dance, called chorea minor to distinguish it from a 
form of hysteria to which the term chorea major has by misfortune 
been given, is a common disease of growing girls, and is far from 
uncommon in boys. It has been well said by Sturges ^ that chorea 
consists in an exaggerated fidgetiness. It is an extravagant exalta- 
tion of that continual unrest which is a natural characteristic of 
childhood. Its movements, that is to say, resemble those due to 
emotion, the same muscles being affected in the same kind of way. 
Consistently with this comparison, the muscles of the upper part of the 
body ar^ much more often affected than the rest, and tiie hands suf- 
fer most of all. The disease is also sometimes spoken of as " Syden- 
ham's Chorea " since he was the first writer to give any accurate 
description of it. He says ^ " This is a kind of convulsion which 
attacks boys and girls from the tenth year to the time of pul^erty. 
It first shows itself by limping or unsteadiness in one of the legs, 
which the patient drags. The hand cannot be steady for a moment. 
It passes from one position to another by a convulsive movement, 
however much the patient may strive to the contrary. Before he 
can raise a cup to his lips he makes as many gesticulations as a 
I mountebank, since he does not move it in a straight line, but has 
( his hand drawn aside by spasms, until by some good fortune he 
brings it at last to his mouth. He then gulps it off at once, so sud- 
I denly and so greedily as to look as if he were trying to anuise the 
, looker>-<^»n." 

I Etiology. — Girls suffer from chorea more than lx>ys, in the propor- 
j tion of about two to one, and about three-fourths of the cases occur 
between the ages of o and 15 years. The disease is rather more com- 
j mon among the children of the i)oorer classes, and is more prevalent 
' in certain localities and among certain races than in others. It ap- 

' ' "r>n Chorea, or St. Vitus's Dance, m Children" (Second E<Htion. London : 
I John Bale & Sons, 1803). 

. « •* The AVorlcs of Thomas Sydenham " (London : The Sydenham Society, 1850), 
f Tol. ii., ProccsBus Integri, xvi. 

15 225 



226 CHOREA. 

pears, for instance, to be relatively rare among negroes in the United 
States, where white children suffer to about the same extent as in 
Great Britain. More cases occur in spring, and, on the whole, the 
seasonal incidence of the disease corresponds very closely with that of 
rheumatism. [Townsend assigns as an important cause of the more 
frequent occurrence of chorea at this season the mental exertion and 
depression arising at the end of the school year. He notices an in- 
crease in the number of cases in October also, cases especially pre- 
disposed to the disease and needing only the excitement and mental 
exertion of a month of school to precipitate the attack.] The sub- 
jects of chorea are generally bright, excitable children, and their his- 
tory shows frequently the existence of some family predisposition ; 
it is not uncommon to find that the mother or a brother or a sister 
has suffered from the disease. Psychical disturbances and emotional 
upset caused by fright, scolding, sudden grief, or injudicious religious 
excitement appear to be common determining causes of an attack, 
which may develop even within a few hours. " Over-pressure'^ at 
school is a cause frequently assigned, but it operates indirectly by 
causing a condition of emotional excitement, just as in adults nervous 
breakdown is commonly due rather to anxiety than to overwork. 
The excitement produced by an approaching examination, or the 
worry due to the unreasonable demands of an unskilful teacher, 
rather than the actual number of hours the child works, are the 
important points. Imitation has been considered as an important 
determining cause, but many of the instances quoted appear to be- 
long to the category of hysteria rather than of chorea ; when imita- 
tion is operative it acts probably through the emotional shock caused 
by seeing a relative or companion reduced to the distressing condi- 
tion which a well-marked attack of chorea produces. A history of 
some accident or injury, sometimes of a surgical operation, is given 
not infrequently, and such cases are to be classed with those follow- 
ing sudden frights. Peripheral irritation, as for instance, intestinal 
worms and nasal pharyngeal disorders, have been assigned as causes 
of chorea, but there is very little evidence for this, and the same 
remark applies to the alleged influence of hypermetropia and hyper- 
metropic astigmatism and other forms of ^^ eye-strain.^' The asso- 
ciation of chorea with inflammatory affections of the joints, pericar- 
dium, and heart, has long been recognized, and it is customary to 
speak of the arthritis and cardiac inflammation as rheumatic ; this 
point will be considered subsequently, but it may be said now that 
rheumatic fever does not appear to predispose, distinctly, to chorea. 
A recent attack of scarlet fever, more rarely of measles, diphtheria, 
typhoid fever, or septicaemia is sometimes assigned as the cause. On 
the other hand the onset of an acute exanthem during the course of 
an attack of chorea commonly suspends the movements. A great 






CHOREA MIXOB. 227 

deal of importance has been assigned to anaMnia as a factm* in the 
pnxUiction of chorea, bnt on insnfficient gronnds : chikhvn frequently 
become anivmic during the attack. In most o^ the cases seen be- 
yond the age of puberty the patient is found to be anaemic at the 
time of onset, but this certainly is not the case in the majority of 
young children attacked. Hysteria produces conditions resembling 
chorea, but does not play any direct part in the production of the 
disease itself. 

[The observations of many American writers with regard to the 
irequency of anaemia in chorea do not coincide with those of the 
author. Rachford especially emphasizes the frequency and impor- 
tance of this condition as an etiological factor in chorea and other 
neuroses in childhood. Though not the essential factor, it probably 
is one of the steps leading up to the explosion of the symptoms known 
as chorea. For, as a result of the ana?mia, the nervous system, as 
well as all other parts of the organism, is in a condition of im- 
poverishment, of partial starvation, and hence is unable to perform 
its functions properly. The cells of the nervous system in the child 
at best are in a condition of extremely unstable equilibrium on ac- 
count of the rapid development and changes which the young organ- 
ism is undergoing. In the anaemic state this instability is greatly 
increased ; the nerve cells are more than ever sensitive and susceptible 
to external and reflex causes. For the same reason the higher centres 
have less inhilntorv power than normal. In this way anannia acts as 
an important predisposing factor in the causation of chorea.] 

Pathology. — Although much has been written upon the pathology 
of chorea, nothing is as yet known with certainty. The occurrence 
of arthritis, pericarditis, and endocarditis indicates that chorea has a 
close nosological relation to rheumatism, but the evidence is by no 
means clear that chorea is merely a rheumatic manifestation. To 
quote the words of Osler.^ " If, as some would have it, chorea is only 
one of the rheumatic states, we have to stretch beyond recognition 
our concept i«»n of the disease, now, in the absence of a knowledge of 
its etiology, necessarily characterized by its symptoms. Very prob- 
ably the cause of chorea will be found to be a poison allied to, but 
not the same as, that of rheumatism." As to the nature of this 
poison nothing is known, though proi)abilities point strongly to its 

;ng a micro-organism capable of multiplying within the body ; 

trious pyogenic micro-organisms have lx*en mentioned, and Pianese 
has isolated and cultivated a bacillus from the nervous system of a 
case of chorea, which when injected into animals caused death prc- 
cede<l by muscular twitching and convulsif»ns. The evidence at 
present, hf>wever, is inconclusive. The frequency with which in- 
flnmraatorA- affections of the joints occur in the course of various 
' "On Chorea and Choreiform Affections" (London : H. K. Lewis, 1894). 



228 CHOREA. 

acute infectious diseases should be borne in mind in this connection. 
There is much to be said for Sahli's theory that chorea belongs to 
the group of diseases of which septicaemia is the most typical mem- 
ber, but it would be a mistake to push the analogy too far, and Dr. 
Sturges thinks that ^^ the heart symptoms of chorea seem best ex- 
plained upon the hypothesis of some pathological kindred between 
it and rheumatism.'^ The morbid anatomy of chorea does not throw 
much light on its pathology. The fatal cases, which are very rare, 
occur generally at or about the age of puberty ; the frequency of 
death is eight times greater between the ages of 15 and 20, taking 
into consideration the number of cases, than under 10 years of age. 
The most constant lesion is endocarditis, which affects, in the vast 
majority of cases, the mitral valve, producing a row of small vegeta- 
tions just within the margin of the auricular surface of the cusps. 
In a few cases death has been proved to have been due to malignant 
endocarditis, and there is some reason to believe that this is a some- 
what more frequent cause of death after chorea, perhaps months 
after, than has been supposed hitherto. Next to the mitral the valve 
most often affected is the aortic, but it seldom suffers alone. At the 
same time endocarditis is not an essential part of chorea, since in 
some cases of death due to chorea in its most typical form, endocar- 
ditis has not been found post-mortem. Pericarditis is a rare compli- 
cation ; when it occurs it is generally associated with endocarditis. 
The most constant morbid conditions observed in the central nervous 
system are those indicative of hypersemia — distension of the peri- 
vascular spaces, which contain many round cells, small areas of soften- 
ing, minute emboli, and haemorrhages. 

The part of the nervous system primarily affected in chorea is un- 
known, but the marked psychical symptoms, the cessation of the 
movements during sleep, and the frequency with which they are 
either limited to one side or are greater on one side than the other 
point to the cortex. As Gowers has observed it is in the motor area 
of the cortex that movements are arranged, ^^ and if they are disar- 
ranged the disorder proceeds from the brain, and we naturally refer 
it to a disordered action of the cells of the cortex.'' A cloudy 
swelling of the pyramidal cells has actually been described. The 
theory that the lesions of the central nervous system are due to 
^^ showers" of minute emboli, derived from the vegetations on the 
mitral valve must be mentioned, but the evidence in its favor is in- 
sufficient. 

The condition of the heart in chorea is a point of much impor- 
tance. Acceleration, unevenness of rhythm, and variability in force 
are almost constant phenomena ; they are aggravated by any excite- 
ment, and may disappear after a little rest in the recumbent posture. 
In addition, in about a third of the cases a distinct murmur, systolic 



CHOREA MIS OR. 229 

ill time, is lieaixl, iii most cases best or only at the apex. ^lore 
rarely, a systolic murmur is heard at the base, generally in the pul- 
monary cartilage, but sometimes at the aortic, and along the left side 
of the sternum in the second, third, and fourth spaces. The mur- 
mur heard in the region last-mentioned is probably in most cases 
functional, that at the a[>ex more rarely. The functional murmur is 
to be attributed either to functional insutiiciency of the cardiac 
muscle ; to aui^emia which, however, is not a common accompaniment 
of chorea, at least in the early stage ; or, perhaps, to the general 
toxa?mia, which ujwn one theory is present in chorea. The systolic 
apex murmur is more often met with the younger the child, and the 
earlier the stage ; it may disappear before the movements cease. 
It is in some cases functional, but in others it is associated with en- 
docarditis (beading of the mitral valve or marked endocarditis), but 
recent statistics ^ appear to prove that in more than half the cases of 
chorea some permanent damage of the mitral valve remains, though 
it may only become evident after some years. Cases of chorea dis- 
tinctly complicated with arthritis are, however, those most likely 
afterwards to suiter from organic heart disease.' Whatever be the 
pathological nexus between chorea and rheumatism, the practical 
clinical point appears to be established that those cases which present 
distinct arthritis possess a less favorable prognosis as to permanent 
heart affections than others. Xephritis is an occasional complica- 
tion. 

In those cases in which the disease develops rapidly, and in which 
the movements are well-marked, the child is usually in an emotional 
state and appears to feel her condition acutely. She has a dull as- 
pect, and is irritable and unable to concentrate attention. The 
movements cannot be controlled by the will, and are aggravated by 
observation or by exertion. Headache is severe in some cases. 
Fever is not observed in the majority of cases of chorea, but is 
present in some at the onset for a few days, but seldom reaches more 
than 100° or 101° F. Higher temperatures are usually due to en- 
docarditis or some other complications. In very acute cases, how- 

I' Especially Osier' s'stati sties from the Philadelphia InHrniarv lor Diseases of the 

Nervous System ; 140 oases were examined two or more years after the attack of 

chorea for which they had l>een under treatment in the infirmary. Of these 51 

•'•.4 per cent.) presented no signs of cardiac disturbance, 17 (12.1 per cent.) 

\ved sifrns of cardiac disturl>ance believed to be functional, and 72 (51.4 j>er cent. ) 

.- --nic heart disease. Of these 72 ca«es 25 had had acute arthritis ( 34.1. S 

that there remainetl 47 ca<es which had sufUrcd from chorea, l»Mt not 

- lism. who yet presented sijems of orjranic diseasefof the heart, that is to 

••y about f»ne-thinl of the total number of old cases of chorea examinetl. 

'Donkin, " Diseases of Childhf»fKl " (London, 181>8i, examined 44 cases two 
rears or more after they had been under treatment for chorea as in-patient** ; of these 
18 had had rheumatism at sometime, and I'i ]irefiented persistent murmurs ; in 26 
there was no history of rheumatism and only 5 had a murmur at the time of ex- 
amination, and in three of these the murmur was nf)t improliably hH-mic. 



230 CHOREA. 



I 



ever, with delirium the temperature may rise to 105° F. In th 
majority of cases the movements aifect all four limbs, and frequently 
the fiice and tongue also, but in not a few they are confined to the 
limbs and face on one side, or are much more marked on one side 
than on the other. In many of these cases of hemichorea paresis of 
the atfected parts is marked and may be the first symptom, so that 
the patient is brought for treatment because it is noticed that one 
hand is weak, and that objects taken into it are dropped. Chorea, 
especially in girls about puberty, may be complicated by maniacal 
excitement, dependent apparently on an hysterical taint. The 
patient may be extremely violent, screaming and biting and scratch- 
ing. The cases are, as a rule, in other respects mild, that is to say, 
the choreiform movements are not very severe. The term chorea 
insaniens is sometimes applied to these cases, as well as to those 
severe attacks in which there is fever accompanied by delirium. 

The course and duration of chorea are very variable. Very mild 
cases may terminate in a few weeks ; but not infrequently they drag 
on for months, temporary improvement being again and again fol- 
lowed by exacerbation, so that the child is never really free from the 
disorder for years. In a well-marked acute case of moderate severity, 
the symptoms generally begin to diminish in two or three weeks, and 
the whole attack is over in eight or nine weeks. Recurrence is, 
however, extremely common. Probably at least half the patients 
suffer one recurrence, many three or four, and some an even greater 
number. 

In the treatment of chorea the most important element is rest for 
body and mind, and general experience confirms the statement of 
Osier that many cases which in the out-patient room seem very 
severe, become mild after a few days of rest in bed and seclusion from 
the anxious solicitude, or ill-timed severity of relatives. When the 
movements are very severe the patient must be protected from injury, 
and from falling out of bed, a not uncommon accident. The mat- 
tress should be soft, the sides of the bedstead covered with cushions, 
and furniture removed out of reach. Care must be taken to prevent 
bed-sores on the back, elbows, or legs. In these very severe cases 
it becomes imperative to give sedatives, potassium bromide or chloral, 
or a combination. Bastian's suggestion to keep the patient continu- 
ally under the influence of chloral is valuable, and gives good re- 
sults in cases which have resisted other forms of treatment ; but the 
treatment is only called for in the worst cases in which the patient's 
life is threatened by want of rest. If the heart be feeble, as is often 
the case, alcohol may be required in pretty full doses. No remedy 
has any direct influence on the course of the disease nor on the 
severity of the movements, although arsenic has been praised as 
possessing power in both directions. To produce any decided effect, 



CHOREA MIXOE. 231 

however, on the movements it must be given in full doses, and has then 
been known to produce peripheral neuritis. In mild cases antipyrin 
is an excellent seilative, the dose being increased gradually until a 
distinct etfect is noticeable. It is well, at the same time, to give 
some preparation of iron. CiHl-liver oil should be given after the 
first severity of the initial disturbance has passed off. The child 
should be given a full and nutritious diet so long as fever is 
absent. Arthritis or endocarditis must be treated by sodium salicy- 
late, but the effect of the drug is somewhat uncertain ; as a rule, 
however, it allays pain. Swollen joints should be wrapped in cotton- 
wool. For the ana?mia which remains after the movements have 
diminished or ceased, iron tonics and a diet containing a large pro- 
portion of fats is to be recommended. The child should not be 
allowed to return to school until the health has been completely re- 
established, and nutrition improved. ^lassage and regular gymnas- 
tic exercises, beginning with the simplest movements, are of value 
chiefly in the later stages when improvement has become arrested, 
and the movements threaten to become chronic. Benefit is also to 
be obtained from the galvanic current applied for ten minutes daily, 
using a large anode applied to the vertex, and the kathode in the 
hand. 



CHAPTER XIX. 
EICKETS. 

Etiology — Pathology — Symptoms — Bony Deformities — Late Kickets — Complications 
— [Early Diagnosis] — Treatment. 

Rickets (rachitis) ^ is a general disorder of nutrition, and its most 
characteristic symptoms are due, probably, to absorption of poisons 
produced in the gastro-intestinal canal by imperfect digestion. It 
manifests itself first, in most cases, during the second six months of 
life, about the time of the first dentition or a little earlier. In Eng- 
land, France, and Germany it is extremely common among the chil- 
dren of the working and poorer classes in towns, but is far from un- 
common in the well-to-do class and in country districts. 

The etiology of the disease is somewhat obscure. Improper feed- 
ing is a determining cause, and overcrowding, want of sun and air, 
and other unhygienic conditions, are contributory causes. There 
must also be a special predisposition, which may be congenital, per- 
haps hereditary, or acquired after syphilis, measles, and other acute 
infectious diseases. The initial error which sets going the processes 
which result in rickets is the use of a diet deficient in some essential 
constituent. Though a defective diet may not by itself be sufficient 
to produce rickets, it is comparatively rare to meet with cases in 
which there is no history of bad feeding. Breast-fed children com- 
monly escape, and when they do suffer they are generally the off- 
spring of mothers exhausted by frequent pregnancies and prolonged 
lactation. Harassing work under bad hygienic conditions and in- 
sufficient food are other unfavorable conditions of the mother's life 
which favor rickets in her child, and to their operation, and perhaps 
also to the influence of heredity, are to be attributed the occasional 
cases of rickets in first-born children suckled by the mother. It is 
common to find that a child suffering from well-marked rickets has 
been weaned early from the breast (within the first three or four 
months of life), and has been brought up on condensed milk, or very 
much diluted '^ fresh'' cow's milk, thickened with some starchy food, 
^' perhaps prepared " by conversion of part of the starch into dextrin. 
[Observation of many cases of rickets in infants, both at the breast 

^ A word coined, according to Skeat, about 1650, with a punning allusion to Gk. 
P^Xf^C, the spine. RickeAy is an English word signifying tottering, from Middle Eng- 
lish urikken, to twist. 

232 



RICKETS. 233 

and on the bottle, has convinced the reviser that in a harge majority 
of the cases deficiency of fat is the most important etiological factor, 
and that rachitis in its earliest stages is in reality " fiit-starvation." 
Analysis of the breast-milk in the breast-fed cases invariably shows 
a low percentage of fat, and the varions '^ foods'' are notorionsly de- 
ficient in this element. It is not an nneommon thincr to see rickets 
developing in children at the breast, food from this sonrce also being 
often entirely insufficient for the purposes of nutrition ; hence we see 
in such infants some form of mal-nutrition developing and most 
commonly rickets.] 

Pathology. — The disease occurs at a period of life when the bone- 
forming tissues are most active, and the stress of defective nutrition 
falls particularly on them, causing excessive and irregular growth, 
accompanied by deficient calcification. In health these tissues are 
found in three situations in a long bone : ((() immediately beneath 
the epiphysial cartilage — the chondroid layer ; (/>) immediately be- 
neath the periosteum ; and (c) the medulla. In a rickety long bone 
the chondroid layer is unnaturally thick and vascular, and instead of 
abutting directly upon hard bone, ends by an irregular edge in 
spongoid tissue which consists of imperfectly formed trabecule, con- 
taining little lime, and loosely arranged so as to leave large alveoli 
containing a soft red marrow\ The sort of cavernous structure thus 
produced has led to the use of the term spongoid. The subperiosteal 
Ix^ne-forming tissue is also increased in bulk and vascularity, so as 
to form a soft layer, thickest in the middle of the sliaft. It is so 
vascular, as well as soft, as to resemble a subperiosteal hjemorrhage, 
and to render the periosteum easily detachable. This is the " osteoid 
tissue" of Virchow ; eventually it becomes very hard bone. There 
is also increased vascularity and overgrowth of the medullary tissue 

f the centre of the bone, and this leads to absorption of good bone 
already formed. Later this loose-structured medullary tissue is 
transformed into fibrous tissue, and finally into very hard, ivory-like 
l)one. AVhen this change is extensive and occurs early, tlic func- 
tional activity of the chondroid layer is destroyed, the epiphysis be- 
comes firmly attached to the shaft, and the bone can no longer 
increase in length. This is one part of the mechanism by which 
rickety dwarfs are produced. In cases which run a more favoralile 
course the spongoid tissue is gradually replaced ])y true ossifying 
tissue. The chemical changes which attend tlicse anatomical lesions 
are, in the main, a diminution of the lime salts (to as little as one- 
third of the normal), and an increase in the amount of water. 

The lK)ny deformities of rickets depend upon two causes: (1) the 
actual increase in bulk ; and (2) the softening of the bones, wlnVli 
allows them to become di^tort^d by muscular action or by the weight 

f the body. 



234 



RICKETS. 



t 



Symptoms. — Rickets varies very much in intensity. The invasion 
may be rapid and attended by fever, gastro-intestinal disturbance 
(thirst, lost of appetite, diarrhoea, abdominal distension), rapid en- 
largement of the epiphyses of the long bones, bossing of the cranial 
bones, and great tenderness of the whole osseous system. The skin 
is warm and perspires readily. The sweating is particularly copious 
at night, or at any time when the child sleeps. It is especially free 
from the head, so that the pillow is drenched. The child is very 
restless when awake, unable to find an attitude in which it can be 
comfortable. Sleep is not sound, the eyes are half shut, and there 



Fig. 18. 



Fig. 19. 





A boy aged 15 mouths, fairly well nourished, presenting rickety conditions of moderate degree. 
Fig. 18 shows the attitude in sitting, but one hand has been raised to exhibit the swelling at the 
wrist. Fig. 19 shows also the backward excurvation of the spine. 

are constant restless movements. These symptoms are to be traced 
to tenderness due to the active changes occurring in the bones. The 
tenderness and the heat of the skin lead the child to kick off the 
clothes. The temperature is higher than normal in the evening. 
Frequently the onset of rickets is very insidious, more often than not 
the earlier symptoms pass unobserved, and the child is first brought 
for the treatment of bronchitis or some other complication, with the 
bony changes already developed. 

The developed disease is always chronic, and the softness of the 
bones, the sweating, and the gastro-intestinal derangement may per- 



BICKETS. 235 

-ist for months or years, often till the end of the long-delayed first 
dentition. By the aetion of various meehanieal ageneies numerous 
deformities are produeed. In the ftkull the disease itself produces a 
thickening and softening of the bones. This change is general, but 
the thickening is most marked at the edges of the anterior fontanelle, 
and at the frontal and parietal eminences. In other cases there is a 
central frontal boss which gives to the skull a peculiar elongated 
cariuate appearance. When the bossing of the eminences is well 
marked the skull assumes a peculiar and characteristic shape to 
which the term natiform has been applied. Associated with this 
bossing:, thouirh seldom when it reaches an extreme decree, areas of 
thin bone may be found. The term cranio-tabcs is applied to this 

Fig. 20. 




Section of a part of a cranial boss, from a case in which cranio-tabes was also present. 
Photomicrograph by Mr. F. Fowke. ) 

• ondition. It is an early sign, and there may be at first, at least, no 
'bvious thickening of the edges of the anterior fontanelle nor bossing of 

the skull. It probably occurs more often in infants who have suffered 
from syphilis than in others. Cranio-tabes is met with usually to- 
wards the back of the head, but it may involve almost any part of the 
cranial vault. AVhen the change is well marked the bone yields and 
as it were crackles under the finger like parchment, often over large 
ireas. In .some cases, most often those in which there is a good deal 

• »f thickening in other parts, the bone in the thin areas is finally com- 
pletely absorbed. The pressure of the head on the pillow may pro- 
luce \cry considerable distortion of the skull, a flattening in the 
intero-pf)Sterior direction, and a broadening from side to side. 
When well developed, cranio-tabes permits considerable pressure to 



236 BICKETS, 

be exerted, which interferes with the intracranial circulation. To 
this cause some are disposed to attribute the special liability of rick- 
ety children to laryngismus stridulus, to eclampsia, and to tetany, 
and they point to the visible distension of the superficial veins at the 
base of the skull and of the jugular vein in support of the view. The 
nervous symptoms mentioned, as well as the venous distension, may 
also be observed in children who do not suffer from cranio-tabes, but 
in whom the skull appears to be everywhere much thickened. It is 
unlikely that in such cases any pressure can be exerted on the cranial 
contents, and it has even been maintained that the brain of a rickety 
child grows with undue rapidity because the cranium, owing to the 
softness of the bones, can be easily distended. 

The first dentition is delayed. The first tooth is cut late, the in- 
tervals between the appearance of the other teeth are prolonged, and 
the natural order of their eruption is disturbed. The teeth are not 
well formed. The cutting border of the incisors is rounded and 
blunt, though this appearance is apt to be modified by the early oc- 
currence of "erosions.^^ The enamel is deposited irregularly, and 
stops short suddenly at the neck. The erosions are of two kinds : 
(1) pits due apparently to defects in the enamel; (2) transverse 
striations, which may be so deep and numerous as to reduce greatly 
the thickness of the tooth. These striations are probably produced 
by stomatitis occurring at about the time when the tooth is being 
cut. In many cases the teeth assume quickly a yellowish color and 
decay rapidly. They may even be carious when cut, and it is not 
uncommon to see all the incisors reduced to mere brown stumps, 
which, however, do not seem to be tender or painful. The form of 
the jaws becomes altered. The lower jaw becomes angular, and 
square in front, compressed at the sides, and the alveolar border is 
bent inwards. The alveolar border of the upper jaw is bent forward 
and the palatine arch is high. The two last mentioned deformities 
have been attributed to the pressure of the tongue in sucking. En- 
largement of the bones of the face is not conspicuous, and the con- 
trast between the large, flat, bossed cranium, and the small emaciated 
face is in some cases striking. 

The deformities of the bones which are of greatest importance as 
they affect the prospect of life are those of the thorax (Fig. 18). The 
simplest form consists merely of a rounded thickening at the costo- 
chondral junction. This row of knobs on either side of the chest is 
the ^^ rickety chaplet,'' one of the earliest and most constant signs of 
rickets. [We cannot agree with this opinion. See below under 
^^ Diagnosis.^^] It corresponds to the enlargement of the epiphysial 
ends of the long bones. It is not in itself of much importance, but 
it indicates the commencement of changes in the ribs which will ren- 
der possible the production of deformities diminishing greatly the 



EICKETS. 237 

capacity of the chest. Kyphosis (Fig. 10) is a deformity which 
commonly develops early : eventually the spine may form one con- 
tinuous backward curve from the neck to the sacrum — " cat's back." 
The auffles of the ribs become unnaturally acute, and the horizontal 
section of the thorax tends to the form of an equilateral triangle, 
with the apex at the sternum. The thorax may remain symmetrical, 
but more often there is some prominence on the left side in front 
corresponding to the precordial region, and at the same time some 
lateral curvature of the spine with the convexity towards the right. 
In association there is some flattening of the angles of the ribs on 
the let\ side, and increased acuteness and prominence of the angles 
on the right. The cause of this lateral distortion is not very clear, 
though it would seem sometimes that the asynunetry originates because 
the heart offers greater resistance to compression than the lungs. 
Lateral curvature with convexity to the right is, however, far from 
invariable, and if the child is carried habitually on the left arm 
of the mother the scoliosis may be in the opposite direction. This 
deformity is produced by the child's body being bent round the 
mother's chest. Under the influence of any disorder which causes 
difticulty in respiration further and more marked deformities may be 
produced. One of these is the formation of a deep vertical groove 
due to a bending-in of the ribs a little behind the costo-chondral 
junction. This throws forward the rib-cartilages and the sternum. 
The sternum also may be bent forward at the junctions between its 
-everal parts. In this way a form of pigeon chest is produced. A 
-econd deformity is the formation of a horizontal groove correspond- 
ing approximately to the insertion of the diaphragm. In forcible 
inspiration the softened ribs tend to bend inwards, and, with imper- 
fect expansion or collapse of the lower portions of the lungs, there 
i- nothing to prevent this tendency until the level of the abdominal 
viscera, the solid mass of the liver and the stomach and colon often 
distended, is reached. The lower part of the thorax is held out by 
the abdominal viscera^ the upper part by the upper lobes of the lungs, 
which are well expanded or perhaps emphysematous, and a groove 
forms in the intermediate region by the falling in of the ribs. The 
combination of these deform ites produces the most characteristic rick- 
ety aspect — the small chest, prominent in front, with the rickety 
r-haplet, horizontal groove, and distended, almost globular, abdomen. 
The pelvis is liable to undergo considerable deformity. It becoines 
shallower, and the iliac crests are nearer together than natural, while 
the antero-su|)erior iliac spines are bent outward. The cavity of the 
jK'lvis may be muoh narrowed l>y inward ])rojections corres|)onding 
tf» the hip-joints, and sometimes also by a pressing forward (jf tlie 
sacrum. The lower aperture of the pelvis is not narrowed. In the 
female these deformities may Ix; the cause of difficult labor. 



238 



RICKETS. 



The deformities in the long hones over and above the enlargement 
of the epiphyses and of the shaft, are produced by external mechan- 
ical agencies, and their character depends upon the habits of the child. 
In an infant, which for the greater part of its life lies on its back in 
a cradle, they will be little marked. In an infant which is carried 
habitually by its mother, some bending of the long bones, those of 
the lower limbs especially, but also of the arms, Avill be produced. 
The exact character of the deformity depends on the attitude in 



Fig. 21. 



Fig. 22. 





Rickety Deformities. Fig. 21 shows especially lordosis and forward bending of the femurs- 
Fig. 22, from the same patient, genu valgum and the small, grooved chest. (From photographs by 
Dr. Percy C. Phillips.) 



which the infant is carried and suckled. In a child which can sit up 
great deformities may be produced. When well marked they are 
very characteristic. The child sits with its legs crossed in the atti- 
tude assumed by tailors — that is to say, with the knees flexed and 
one leg crossing the other at, or just above the ankle (Figs. 18-19). 
The hands rest usually with their palmar surfaces on the bed beside 
the hip-joints. The heels are drawn up close to the perineum, and 
the weight of the child is borne mainly on the nates and the hands. 
In consequence, excurvations of the bones of the upper limb, but es- 
pecially of those of the forearm are produced, so that the whole 



BICKETS. 



239 



limb is bowed outwards. In the lower limbs the main deformity is 
in the bones of the leg, and is produeed at the point where the legs 
cross each other. If, as is often the case, the child sits habitually 
with the same leg uppermost, the tibia of this leg is bowled inwards 
(upwards as the child sits) andiUher leg outwards (downwards as the 
child sits). The deformity in the femur is less, and consists in a bow- 
ing forwards ; children who have acquired this attitude seldom learn 
to crawl ; their earliest mode of progression is to push themselves 

Fig. 23. 




Skiagram .sbowiug the curving of the bones in a case of genu valgum. (Mk. <\ A. Morton's 
case.) 

along the floor in a sitting posture throwing the weight of the body 
mainly on the arms, and progressing by working tlie nates forward, 
first on one side and then on the other. When the child begins to 
walk early it often becomes bow-legged. This habit tends to main- 
tain and aggravate the deformity of the upjKT limbs. After the age 
of infancy the rickety deformities of the lower limbs may be at- 
tended bv lordosis (Fig. 21), and in many cases knock-knee is pro- 
duced (Figs. 21, 22, and 23). 



240 RICKETS. 

In rare cases rickety deformities begin to make their appearance 
at the age of twelve years or later. The causes of the condition ap- 
pear to be similar to those which produce rickets at an earlier age, 
and the pathological process is identical. Such cases are therefore 
justly denominated late rickets. 

Among cases of rickets two clinical types are generally recognized 
— small and large. In small rickets the child is small and thin and 
light for its age, and often precocious. The enlargement of the bones 
is confined commonly to the epiphyses and is not extreme. In large 
rickets the child is big and fat, and dull rather than precocious. The 
cranial and other bony changes are well marked, and the copious 
perspirations are a source of much discomfort. Small rickets is met 
especially among the neglected children of the poorest class ; their 
food is often defective, not only in quality but in quantity, and they 
suffer from chronic diarrhoea. The child with large rickets is com- 
monly well cared for, and fed copiously on condensed milk and pre- 
pared food. It is seldom free from some bronchial catarrh, and 
suffers from frequent attacks of bronchitis. 

Complications. — Gastro-intestinal catarrh is a common accompani- 
ment of all stages of rickets. Dyspepsia and diarrhcea are so fre- 
quent at the onset of the disorder that they have been regarded as 
the determining causes. At a later stage catarrh of the large intestine 
is very common, and the stools are frequent, consist largely of 
mucus, and are often very foul-smelhng. Lienteric diarrhoea is not 
uncommon, and in other cases the child suffers from alternating 
diarrhoea and constipation. Rickety children are very liable to suffer 
from diarrhoea in hot weather, and slight errors of diet will in them 
determine an attack. They are especially liable to bronchitis and 
broncho-pneumonia. These diseases are particularly dangerous in 
them, owing to the diminution in the capacity of the chest, which, if 
it does not already exist, is quickly produced. Owing to the readi- 
ness with which the chest walls yield, bronchitis is peculiarly liable 
to be complicated by collapse, which paves the way for broncho- 
pneumonia. For the same reason the pulmonary circulation quickly 
becomes embarrassed, and dilatation of the right side of the heart 
contributes to bring about a fatal termination. 

[Diagnosis. — Too much importance cannot be attached to an early 
diagnosis of rachitis, for it is in its earliest stages that treatment is 
most successful. It is a preventable disease, provided the child be 
born healthy. If the diet be carefully regulated and the infant re- 
ceive the proper amount of fat and albumenoids, either in breast- 
milk or modified cow's milk, rickets will not develop. If, however, 
the child fail to receive a proper amount of these elements he will 
soon show signs of disturbance. If rickets be developing, head- 
sweating, restless sleep and constipation will soon be noted. The 



BICKETS. , 241 

occurrence of these three symptoms in a nursling should at once j)ut 
us on our guard and lead to an investigation of the infant's food, and 
wherever possible a chemical analysis cither of the breast-milk or of 
the bottle-food. They are the earliest signs in the development of 
rachitis, occur long before bone changes are manifest clinically 
and should serve as a danger-signal, foretelling serious disturbance 
in the child's nutrition. If analysis of the food show a diet de- 
ficient in either fat or proteids, we may feel sure that sooner or later 
the characteristic bone-changes will follow. The diagnosis then is 
of course an easy matter, but by that time nuich mischief has been 
done which could have been prevented. Careful inquiry into the 
details of the intant's life will too often bring out the above tripod 
of symptoms, and it is at that stage that our treatment should be in- 
stituted. The physician is rarely consulted for these conditions, but 
he will find them on investigation when called for some intercurrent 
disease. Esi>ecially will he find them in the daily routine of large 
city clinics among the half-starved nurslings of equally half- starved 
mothers. The occurrence of rickets in infants fed on one of the so- 
called " baby-foods " is too common to need more than a passing 
mention.] 

The treatment of rickets consists in the main of the correction of 
these errors of hygiene and diet which are believed to be its chief 
causes. The child should live in well-ventilated rooms and should 
have fresh air daily; if it be suitably clothed in woollen garments, 
there are few days in the year even in a British climate when it may 
not be out for several hours. While active softening of bones is in 
progress it should be carried as little as possible in the arms, and 
should go out in a cradle-perambulator. The (Uet must be carefully 
inquired into, and any errors corrected. Milk is the best food, but 
one or two meals a day of well-cooked fine oat, or other whole meal, 
may Ix? given after the age of one year, or even a little earlier. If 
the patient is an infiint at the breast it should not be weaned until 
after the age of twelve months, unless the mother's health has be- 
come much deteriorated ; and even so, it is often better to endeavor 
to improve her nutrition, and to supplement the breast-milk than to 
wean the infant. At a more advanced age the child should have a 
nutritious diet containing a large proportion of fats and of proteids. 
Starchy foods should nr»t form the staple article of diet. Fresh fruit 
is well taken if there be no great gastro-intestinal irritation, and when 
the patient is anaemic its use forms one of the most important parts of 
treatment. The child should have a hafh daily ; this must be warm 
for infants and for fragile children at all times of the year — but cold 
effusions to the limbs should lie used if they do nf>t cause the patient 
too much distres.s. Salt baths are also of use, owing to their stimu- 
lating effect on the skin. Change of air, especially to tiie McasidCf is 
16 



242 RICKETS. 

very beneficial, and then warm sea baths should be prescribed. Mas- 
sage of the limbs is useful, and should be used except when the ten- 
derness is too acute. Diarrhoea, bronchitis, and other complications 
must be treated by the remedies appropriate to the several forms of 
these disorders, as indicated elsewhere. Atropine (gr. y-J-Q-) may be 
given in the evening to check sweating. It is essential to get the 
digestive system into good order before any permanent benefit can be 
expected from other remedial measures. No drug has any specific ac- 
tion on the course of the disease. Phosphorus, for which this power 
has been claimed, is of value only during what may be called the 
acute stage, when tenderness is extreme and copious sweats are un- 
dermining the strength and exposing the child to the risk of catching 
cold while out of doors. It may be given in cod-liver oil, or, if this 
cannot be tolerated by the stomach, in solution. The dose should be 
from yi-Q to -^-^ grain. [One of the folloAving preparations may be 
used : 

Tincture Phosphor! Composita (B. P. C. )• 
Phosphorus, gr. iij 

Chloroform, 3'^ 

Warm gently in a stoppered bottle till dissolved, and add the solution to ethylic 
alcohol 5^^- Shake and keep in the dark (1 in 600). 

Elixir Phosphori (B. P. C). 
Tr. PhosphoriCo., 5j 

Glycerine, 5^^ 

To be prepared freshly : contains gr. 1/50 in 5j- Dose for an infant TTLx-xx. 

Oleum Morrhuge Phosphoratum. 
01. Phosphorati (B. P. ), 5ij Ti^xl 

01. Morrhuffi, Oj 

Contains 1/100 in 5jj which is the dose. Appendix.] 

The greatest benefit is derived from the continuous administration 
of cod-liver oil, which may almost be claimed to be a specific. It 
should be given at first in small doses, which should be increased as 
tolerance is established. An infant of one year, if its digestion be 
in good order, can usually take a drachm twice or even thrice a day. 
It should be given alone or with malt extract, or if this fail, in 
emulsion, guarded, if there be tendency to diarrhoea, by half a drop 
of tincture of opium. If after a fair trial it appears that cod-liver 
oil cannot, at the time, be borne, it may be replaced by a syrup of 
the phosphate of iron, or by the ammonio-citrate of iron. Deformi- 
ties of the long bones must be treated by suitable splints and by 
massage so long as the bones are still soft. At a later stage, when 
osseous sclerosis has occurred, the question of osteotomy or osteoclasis 
will arise ; but when treatment, hygienic and local, can be carried out 
early with sufficient perseverance and skill, very remarkable im- 
provement may be obtained without surgical interference. 



CHAPTER XX. 
SCURVY. 

Age — Etiology — Morbid Anatomy — Symptoms — Course — Treatment. 

No age is free from the liability to .<ciirw, but in infancy tlic di.-^- 
order presents certain special characters, owing, apparently, to the 
great physiological activity of the growing parts of the bones at that 
age, and the j^culiar liability to rickets. 

Age. — It is rare for a child to sutler from scurvy before the age 
of nine months, and the period during which the disorder is most 
often seen is between that age and about eighteen months. 

Etiology.^ — The age at wliich infantile scurvy has been observed 
most often, covers the period during which a child weaned early from 
the breast is most likely to be kept on a rigid diet. The disease is 
certainly more common among the children of the well-to-do classes. 
This fact is to \ye attributed to the prevailing habit of feeding infints 
entirely on projirietary foods made of starch, and on sterilized or 
condensed milk. The children of the poor may have similar prep- 
arations in their bottles, but they begin at a very early age to pick 
up a certain amount of food at the general table, whereas with the 
strict discipline of a well -dragooned nursery this natural habit is 
suppressed. Condensed milk, and the various kinds of commercial 
milk preparations sufficiently well sterilized to keep for months, as 
is the case with some humanized milk, are also causes of scurvy if 
used to the exclusion of fresh milk. Even fresh milk, if too much 
diluted, may not prevent the onset of scurvy, and the same may be 
said of scalded milk, and perhaps of milk sterilized for short periods, 
though not of pasteurized milk. Want of fresh air and sunlight may 
be contributory cau.-es, but syphilis, rickets, and other constitutional 
disonJers which produce marasmus, do not produce scurvy unless 
fresh food b deficient. The actual onset of the attack appears to be 
determined in some cases hy an injury, in others by a sudden in- 
crease in the dilution of the food given. 

Morbid Anatomy. — The characteristic lesion is subperiosteal luem- 
rrhage, but this may l>e absent if there be no rickets. The perios- 

' Barlow's views as to the Etiology and Pathology of Infantile Scurvy, though not 
universally accepted, appear to me to be correct, and have been followed here. See 
hit Bradshaw Lecture {BrU. Med. Jour., 1894, vol. ii., p. 1029). 

243 



244 SCUBVY. 

teum is intensely vascular, and the amount of eifused blood between 
it and the shaft of the bone may be very considerable. Haemorrhage 
takes place also into the cavity of the shaft, causing destruction of 
trabeculse and leading in time to absorption of the compact tissue. 
Blood is eflPused also into and between the muscles near the bone, 
and serous effusion is found in their more superficial parts. Proptosis 
is due to extravasation between the periosteum and the roof of the 
orbit. The swellings over the cranial bone are due to extravasa- 
tions under the scalp, generally in relation with portions of bone 
previously rendered unduly vascular by rickety changes. Hsema- 
toma of the dura mater also may be produced. Haemorrhage, which 
may be extensive, may also occur into the lungs, and minute haemor- 
rhages may be found in the intestinal mucous membrane, mesenteric 
glands, and the pyramids of the kidney. Occasionally small haemor- 
rhages take place into the joints. In a case w^hich has reached a 
more advanced stage, and in which the process is receding, a layer 
of bony tissue will be found on the under detached surface of the 
periosteum, and the muscles will be much wasted. 

Symptoms. — The previous history of the child may have been quite 
uneventful, or there may have been much difficulty in finding a food 
Avhich it could digest. In any case it will have been hand-fed. The 
first symptom noticed is that the infant becomes difficult to handle ; 
it cries whenever it is touched, but is fairly quiet when left lying down. 
It keeps the lower limbs drawn up, and it is evident that they are 
tender. A little later some swelling — first of one lower limb, thigh 
or leg, then of the other — can be detected. There is no local heat, 
redness, or pitting, and the swelling, which is not well defined, ap- 
pears to be in relation with the shafts of the bones. Later, the swell- 
ing in these situations becomes greater, there may be a little oedema, 
and the skin may have a purplish tint, but this is seldom very pro- 
nounced. The attitude in which the child lies is changed, the legs 
are everted and motionless, so that the infant is thought to be para- 
lyzed, an opinion apparently confirmed by the weakness of the back. 
Some swelling of the upper limbs, above the wrists, and near the 
epiphyses of the humerus, may now be perceived, and also perhaps 
some fulness over the scapulae. The lesions, though not exactly 
symmetrical, are yet commonly present on both sides. The joints 
are not affected, but at an advanced stage of the malady crepitus may 
be obtained at about the junction of the epiphysis and diaphysis of 
the femur (upper and lower) and tibia (upper) or more rarely the 
humerus. Occasionally, fracture occurs in the middle of the shaft of 
tlie femur. A peculiar deformity of the chest may appear ; the 
whole front of the thorax, including the sternum, costal cartilages, 
and the anterior parts of the ribs, sinks in as though the ribs had 
been fractured in a row just beyond the costo-chondroid junctions, 



SCURVY. 245 

which indeed is the case. In a lew instances areas of thickening 
may be made out over tlie cranial, and sometimes even the facial 
bones. The areas are tender, but there is no local heat and seldom 
any change of color. Proptosis first of one and then of both eye- 
balls, with puftiness and some staining of the lids, may develop 
somewhat suddenly, with perhaps some ecchymosis of the ocular 
conjunctiva. The state of the gums depends upon the stage of den- 
tition which has been reached. If no teeth have been cut, the gums 
are normal, or present only some purple stains where the teetli are 
about to appear. If a few teeth have been cut, they will be sur- 
rounded by narrow fleshy ridges ; if many, the sponginess of the 
gums may be so great that fleshy masses protrude from the mouth. 
Such spongy gums bleed easily, give rise to much ftetor, and inter- 
fere with feeding. Epistaxis may occur, and occasionally blood has 
been passed from the bowel, but digestive disturbance is not a 
marked or a necessary symptom, though loss of appetite is the rule. 
The urine often contains a trace of albumen, sometimes blood. The 
heart and lungs show no signs of disorder. The spleen may be a 
little enlarged. The most marked general symptom is ana?mia, 
which is proportional to the degree in which the bones are involved. 
The infant becomes very pale, and after a time the skin assumes an 
earthy tint, and petechiae, or larger ecchymoses appear. There is 
also extreme prostration, though there maybe little or no emaciation. 
There is no regular pyrexia, but as each fresh limb is attacked the 
tenn>erature may rise for a day or two to 101° or 102°F. 

Course. — If untreated the cachexia becomes very profound, and the 
infant commonly succumbs to some intercurrent affection — bronchitis, 
pleuro-pneumonia, diarrhrea, or a specific fever. If these dangers 
be escaped, improvement begins in two, three, or four months. 
The swelling of the limbs, and with it the tenderness, diminishes, 
leaving a firm swelling around those parts of the bones which were 
most affected. This is the more evident owing to wasting of the 
muscles. After a time fractures, if they have occurred, unite with- 
out much deformity, except those which involve the middle of the 
I shaft, where much callus may be thrown out. Anaemia and asthenia 
I disappear gradually. On the other hand, under proper treatment 
recovery is very ra])id. 

The symptoms detailed are those of well-marked cases, but it is 
, probable that mild degrees of scurvy are resj)onsible for cases in 
I which with moderate signs of rickets there is excessive tenderness, 
' and some anferaia, symptoms which are quickly relieved by giving 
j fresh frxxl. Hiematuria may Ix.' the solitary sign of scurvy, and 
I possibly also ]>roptosis. 

I The treatment is simple and satisfactory. The infant must l)e put 
upon a diet of fresh food suitable to its age. Fresh whole milk is 



246 SCURVY. 



1 



the best. It should be given undiluted. To it, or to milk diluted 
not more than by the addition of one part of water to three of milk, 
may be added a little sieved potato. A tablespoonful of orange or 
grape juice may be given in water during each day, and to children 
a little older about the same quantity of fresh meat-juice, or gravy. 

[Raw Meat-Juice. — Mince fine one-quarter pound best rump-steak, 
free from fat and gristle, add two tablespoonfuls of water, stir, and 
set aside for one hour. The juice is expressed through muslin by 
twisting. From 2 to 3 fl, oz. may be given in twenty-four hours. 
It may be given in milk, the taste of which it does not much 
modify. (Cheadle.) 

Raw Meat Pulp. — Take 2 oz. of best rump-steak, scrape fine with 
a knife on a cook's board, removing all gristle and fat. If not quite 
pulped, pound in a mortar. May be taken alone, mixed with a little 
finely minced parsley (about half a teaspoonful), or spread between 
thin slices of bread. At one year, this quantity may be given during 
the day. Appendix.] 

The child should be kept at rest in the horizontal position, which 
not only prevents him from suffering the pain which handling 
causes, but obviates the danger to heart failure which is liable to oc- 
cur in extreme anaemia and debility. All the symptoms diminish 
rapidly under this diet, and in a short time it may be necessary to 
reduce the amount of fresh undiluted cow's milk and vegetable which 
is at first greedily taken and assimilated with ease. Local conditions 
require treatment only in extreme cases ; thus it may be necessary to 
apply splints for fracture, and to use antiseptic and astringent ap- 
plications for bleeding from the gums. Subcutaneous and periosteal 
haemorrhages should be treated by gentle pressure maintained by 
pads of cotton- wool. 

Prevention. — Scurvy seldom comes on before the ninth month. It 
is, therefore, about the eighth month that the diet of a hand-fed in- 
fant should be considered with a view to its prevention. If fresh 
milk can be obtained from a reliable source, and can be digested 
whole or very little diluted, it will be sufficient to continue its use. 
If, as is commonly the case in towns and during hot weather, the 
milk must be boiled, it may be thickened with freshly sieved potato. 
If this is not well taken, as sometimes happens when there is gastro- 
intestinal catarrh, fresh meat-juice or gravy, about a tablespoonful of 
either should be given daily. Frequently infants of a year old, or 
even less, will take fresh ripe fruit with pleasure, and without dis- 
comfort. Indeed, it is curious to see how many young children 
will suck with satisfaction at an orange or, even, a lemon, which is 
so sour that to the adult palate it is extremely distasteful. 



CHAPTER XXI. 
AX.EMIA AND LEUCH.EMIA— HAEMOPHILIA. 

[Normal Blocni in Early Life] — Secondary Anaemia — Primary Ana^nia — Chlorosis — 
Progressive Pernicious Anaemia — Splenic Anaemia — Leucluvmia — Hodgkin's 
Disease — Hiemophilia. 

Both the white and red blood-corpuscles and the amount of haemo- 
globin are stated to be above the average at birth. There are also a 
few nucleated red corpuscles, but immediately after birth there is a 
diminution in all these constituents. 

[This diminution, however, is not sufficient to bring the number 
ro the average of adults, and, as we should expect from the generally 
undeveloped state of the infant and child, we find in the blood of 
these periods considerable variations from the normal as found in 
adults. The number of red corpuscles is generally somewhat higher, 
averaging a little over 5,000,000 per cubic millimetre. During the 
first few weeks of life, we see variations in the size and shape of the 
corpuscles and also see, more commonly, nucleated reds. The differ- 
ence, however, is more marked when we come to an estimation of the 
various fonns of leucocytes. The following table illustrates averages 
as given by Cabot, Gundobin, Moi-se, Rotch, and others : 

Infants. Adults. 

Small Mononuclear 1 „ 50-70 per cent. 24-30 per cent. 

Large " - ; young cells. g-U - 3- 6 - 

Neutrophiles (adult cells) 18-40 " 60-75 " 

Eosinophiles (old cells) ^-10 " 1-2 

In other words, we see an increase in the '^ young" and a diminu- 
tion in the ''adult" cells. These proportions it is important to bear 
in mind in making a differential count of the white cells. This count 
may l^e made as follows : Cover-glasses are cleaned with soap and 
water or with alcohol, the ear is punctured and a cover-glass touched 
to the drop of ])lood. Ujxin the cover, another is placed and the 
blr>od thus spreads out between them. They are then drawn care- 
fully apart, heated over the flame of an alcohol lamp for thirty to 
sixty seconds and covered for the same length of time with the Ehr- 
lich tricolor mixture, prepared as follows : 

Ehrlich — Biondi Powder, gr. xv 

Alcohol (absolute), 1 c.c. 

Distilled water, 6 c.c. 

(Cabot.) 
247 



248 AN.EMIA AND LEUCHJEMIA—HMMOPHILIA. 

Wash with water, dry and mount in Canada balsam, examine with 
the oil-immersion lens. 

For more delicate work, it is advisable to heat the specimens for 
an hour at a temperature of 110°-115° C. and then to stain for 
three or five minutes, but for ordinary clinical work, the shorter 
method is sufficient. 

The actual counting is simple and consists merely in checking off 
the different cells and putting them under their respective headings. 
Cabot states that one thousand cells should be counted. 

Plate II., from Park's Surgery, shows the different types of leuco- 
cytes, varieties of red corpuscles, and the appearance of the blood in 
various pathological conditions.] 

Very numerous investigations have been made upon changes in the 
blood produced by disease. The changes in the cellular constituents 
include diminution in the number of red cells, and in the amount of 
hsemoglobin, an increase in the number of leucocytes, and the pres- 
ence of certain abnormal white cells. To all these conditions the 
term anaemia is commonly applied, though for that last mentioned 
the term leuchsemia is more appropriate. 

[The changes are exaggerated and more marked in the blood of 
infants and children than in that of adults. The whole of the young 

DESCKIPTION OF PLATE II. 
Blood. 

Fig. I. Types of Leucocytes. — a. Polymorphonuclear Neutrophile. h. Poly- 
morphonuclear Eosinophile. c. Myelocyte (Neutrophilic), c^. Eosinophilic Myelo- 
cyte, e. Large Lymphocyte (large Mononuclear). /. Small Lymphocyte (small 
Mononuclear). 

Fig. II. Normal Blood. — Field contains one neutrophile. Eeds are normal. 

Fig. III. Anemia, Post-operative (secondary). — The reds are fewer than nor- 
mal, and are deficient in haemoglobin and somewhat irregular in form. One normo- 
blast is seen in the field, and two neutrophiles and one small lymphocyte, showing a 
marked post-hfemorrhagic anaemia, with leucocytosis. 

Fig. IV. Leucocytosis, Inflammatory. — The reds are normal. A marked 
leucocytosis is shown, with five neutrophiles and one small lymphocyte. This illus- 
tration may also serve the purpose of showing the leucocytosis of malignant tumor, 
except that in this disease (malignant) the reds show a well-marked secondary anaemia. 

Fig. Y. Trichixosis. — A marked leucocytosis is shown, consisting of an eosino- 
philia. 

Fig. VL Lymphatic Leukemia. — Slight anaemia. A large relative and abso- 
lute increase of the lymphocytes (chiefly the small lymphocytes) is shown. 

Fig. VII. Spleno-myelogenous Leukaemia.— The" reds show a secondary 
anaemia. Two normoblasts are shown. The leucocytosis is massive. Twenty leuco- 
cytes are shown, consisting of nine neutrophiles, seven myelocytes, two small lympho- 
cytes, one eosinoi)liile (polymorphonuclear) and one eosinophilic myelocyte. Note 
the polymorphous condition of the leucocytes, i. c, their variations from the typical 
in size and form. 

Fig. VIII. Varieties of Ked Corpuscles. — a. Normal Eed Corpuscle (nor- 
mocyte). 6, c. Anaemic Red Corpuscles, d-g. Poikilocytes. li. Microcyte. i. 
Megalocyte. j-n. Nucleated Red Corpuscles. J, k. Normoblasts. I. Microblast. 
m, n. Megaloblasts. ( Prepared by Dr. I. P. Lyon. ) 



f^/ 







FtyV/// 



6o6t'4QU(^^44«g 



pmn—mmr^mti 



SECOXDARy AX.EMIA. 2-49 



i>v. 



organism is more sensitive to, and more seriously disturbed b 
morbid proeesses than is the adult, and the blood but shares in this 
general peculiarity. As in all the processes of these periods, both 
physiological and pathological, irregularity and instability are marked; 
hence slight causes produce greater disturbances. The blood, there- 
fore, is easily affected, shows changes quickly, and the relative pro- 
portion of the whites is disturbed. There is a general tendency to revert 
10 the fcetal type of blood. Leucocytosis is more easily produced and 
to a greater degree, and is generally a lymphocytosis, the infantile type. 
Splenic enlargement is common in all the anaemias of infancy.] 

Ana?mia may be primary, due to a disorder of the blood itself, or 
-ocondary, due to derangement of other organs of the body. The 
ic-ndency of recent observations is to reduce the number of forms of 
ana?mia which can properly be regarded as primary. 

Secondary anaemia may be due to a variety of causes and is a 
common complication of a large number of diseases. It may be due 
o (1) inanition, in which all the elements of the blood are reduced ; 
'2) to ha:niorrhaf/e ; here the number of red corpuscles is at first 
educed and those presen-t vary in size and some are nucleated (see 
Fig. 3, Plate II.) ; the haemoglobin is reduced in greater proportion 
than the corpuscles. The leucocytes are increased in number, owing 
mainly to the presence of a larger proportion of polynuclear cells ; 
.'>) pi/rexia, from whatever cause, produces anaemia, owing partly to 
lestructiou of cells and partly to deficient production. It may or 
may not be accompanied by an increase in the number of white cells, 
which is observed especially in pneumonia, but also in pericarditis 
and endocarditis, in pleurisy, in pyogenic diseases including purulent 
meningitis, septicaemia and osteo-myelitis, in acute rheumatism, ery- 
sipelas, diphtheria, scarlet fever, and small-pox. In tuberculous 
liseases, including tuberculous meningitis, there is said to be no leu- 
'►cytosis except in advanced pulmonary disease when it may perhaps 
•e attributed to the suppuration. Leucocytosis does not occur in 
measles, typhoid fever, influenza, malaria, or peritonitis. [Other 
autliorities find that this is true only of the tubercular variety and 
his is also the reviser's experience. Septic peritonitis, however, 
tlways is accompanied by leucocytosis, except in those severe cases 
vhere the organism is so overwhelmed by the disease that it makes 
110 resistance. Absence of leucocytosis under these conditions is a 
/rave prognostic sign.] Ana?mia may also be produced by the ac- 
ion of certain chronic conditions which produce toxaemia, including 
-yphilis, rickets, chronic malaria, Bright's disease, chronic suppura- 
ion, rapidly growing tumor, and certain mineral poisons, es])ecially 
lead, arsenic, and mercury. In these conditions the red corjuisMcs 
are reduced in number and in size, but, as already sinM. the condi- 
tions as to the increase of the white cells varies. 



250 AN^3nA AND LEUCH^MIA—HJEMOPHILIA. 

The conditions usually classed as primary anaemia are chlorosis and 
pernicious annemia. 

Chlorosis, in which the characteristic alteration is a diminution in 
the amount of haemoglobin without a corresponding decrease in the 
number of red cells, and without any considerable leucocytosis, is 
rare in childhood, but becomes common in girls at about the age of 
puberty. There is a progressive loss of strength, and increase of 
pallor, without Avasting. The appetite is small and capricious, the 
bowels constipated. The greenish tint of skin to which the dis- 
ease owes its name is never marked in childhood, and the face is often 
flushed. Deficiency in haemoglobin renders the patient breathless on 
slight exertion, palpitation is easily provoked, and a systolic bruit is 
heard, generally at the base in the second space on the left side, but 
occasionally as low as the fourth space. There can be no doubt of the 
value of iron in the treatment of chlorosis, but when, as is the rule, 
constipation exists, this must be relieved, before the full effects of 
the remedy can be obtained. Of the preparations of iron probably 
the best is the perchloride, which must be given in full doses. The 
aloes and iron mixture (B. P.) is a very useful preparation, but as a 
rule salines are to be preferred as laxatives. Sulphate of magnesia 
may be given in solution in combination with sulphate of iron. 

[Our efforts in treatment are directed towards increasing the amount 
of haemoglobin, as an increase in this element is essential to resti- 
tution to health. The principal place of origin of this constituent of 
the blood is the intestines. Forchheimer believes we shall get our 
best results in treatment by giving before meals some intestinal anti- 
septic, such as salol or hydro-napthol, and after meals blood in one 
form or another. In this way the destruction of the precursors of 
haemoglobin is prevented, and the haemoglobin-producing function of 
the intestine is utilized to the utmost. Iron compounds may be 
used instead of a blood-preparation, but progress is less rapid.] 

Progressive pernicious anaemia is a form of haemolysis due 
usually to intestinal toxaemia ; it may perhaps be caused by syphilis. 
An analogous condition has been traced in adults to intestinal 
parasites. The condition is very rare in childhood. The red cor- 
puscles are few in number, large, some irregular in form, and some 
nucleated. [Megaloblasts. See Fig. 8, Plate IL] They are rel- 
atively rich in haemoglobin ; the leucocytes are as a rule not in- 
creased and may even be diminished in number. There is usually a 
history of long-standing gastro-intestinal derangement, and dyspepsia, 
vomiting, and diarrhoea are symptoms in nearly all cases. The prog- 
ress of the disease is marked by a continuous increase of pallor of 
the skin and mucous membranes, general weakness, wasting, and 
loss of energy. The onset may be gradual, but the symptoms some- 
times follow upon a shock. Haemorrhages into the skin and mucous 



SPLEXIC AX.EMIA. 251 

membrane and retimi ofter occur. The pulse i> full auil throbbing, 
cardiac palpitation is rare, but luemic niurnuirs are heard. The 
symptoms are usually progressive, but intermissions may occur, and 
under the influence of arsenic complete recx)very has taken place. 
In the treatmcnf of the disease the administration of arsenic should 
be }>receded and accompanied by rcirulation of the bowels, the use 
t* intestinal antiseptics, and careful rcixulation of the diet. 
Splenic Anaemia. — In infants and children up to about the age of 
three years, marked anjemia, attended by enlargement of the spleen, is 
not uncommon. Some of these cases are due to syphilis, rickets, and 
chronic tuberculosis ; others are examples of splenic leuchaMuia ; but 
a considerable number remain which cannot be accounted for under 
any of these heads. When the patient first comes under treatment, 
the enlargement of the spleen is usually considerable and often enor- 
mous. It extends downwards and towards the middle line, and 
may occupy eventually the whole left flank, reaching beyond the 
umbilicus and so far downwards that the fingers can only be inserted 
between the iliac crest and the spleen by pressing the organ upward. 
The size of the organ is subject to variations, whieh may be, in some 
cases, traced to attacks of diarrhcea. The causation of the condition 
is obscure. Syphilis and rickets, the causes usually assigned, do 
not account for a large projx^rtion of the cases, more especially those 
in which the ana?mia and enlargement of the spleen is most pro 
nounced. The pallor of the skin may be extreme, and it has usually 
a yellow tinge. There is slight oedema of the subcutaneous tissue, 
and the skin is dry and glazed, so that the aspect recalls that of a 
wax model. In some cases petechia appear, fade, and again api>ear 
>n several occasions. There is a reduction in the number of the red 
'lis and of the haemoglobin ; the white cells may or may not be in- 
reased in number. Von Jaksch has proposed to make a distinct 
lass of those cases in which considerable permanent leucocytosis is 
jiresent, and has applied the term aiueinia infantum pseudoleuchcemica 
to the condition. Though neither splenic anaemia nor the special 
form described by Von Jaksch ap})ears to threaten life, or to l)e pro- 
gressive in the sense in which this term is applied to pernicious 
ansemia, the prognrms is not good, general nutrition is not maintained, 
the child does not increase in height or weight to a natural degree, 
and is very apt to succumb to some inter-current disorder, especially 
pneumonia, measles, or an acute intestinal affection. In the treat- 
ment, attention should first be given to the gastro-intestinal disorder 
vhieh is nearly always present, and in my experience little good re- 
dts from the administration of iron until diarrhoea has been checked 
and digestir»n improved. The condjination of the citrate of iron and 
ammonia (gr. iij to iv for a child of two) with a minute dose of 
rychnine, is to be recommended at first, followed, when improve- 



252 ANEMIA AND LJ^UCHjEMIA—HjEMOPHILIA. 

ment has become established, by perchloride of iron. If there be 
reason to suspect syphilis, mercurials should be used in addition to 
the remedies already mentioned. 

Leuchaemia is the term applied to conditions in which the blood 
contains certain abnormal white corpuscles. Two forms may be 
distinguished : (1) spleno-medullary , in which the blood contains cor- 
puscles derived from the marrow of bone (Fig. 7, Plate II.) ; and 
(2) h/mphaticy in which the blood contains elements derived from the 
lymph glands (Fig. 6, Plate II.). Leuchaemia is a disease of middle 
life, but may occur in infancy, and congenital cases have been de- 
scribed. The spleno-meduUary form is less uncommon. The blood 
contains a great excess of white corpuscles, the most remarkable 
change being the presence of large mononucleated cells with granular 
protoplasm derived from the marrow [the so-called " myelocytes '^ 
Fig. 1, c, Plate II.] ; the red corpuscles, of which some are nucle- 
ated, are reduced in number, and the haemoglobin in greater propor- 
tion. The cause of the condition is obscure ; malaria, syphilis, and 
injury have been assigned, and the disease has also been attributed 
to a specific infection. The enlargement of the spleen may be very 
considerable ; vomiting is usually an early symptom and may be very 
persistent ; diarrhoea may be very severe, and is sometimes due to 
colitis. The urine contains an excess of uric acid ; the pulse is 
rapid and soft, and there may be a hsemic murmur. In children 
dyspnoea is seldom a marked symptom until the anaemia has become 
extreme. Petechise are frequent, and in some cases large ecchymo- 
ses occur. Epistaxis and bleeding from the gums are not uncommon, 
but haemorrhages from other sources are rare. The retina may be 
the seat of inflammation secondary to extravasation, or of small 
leucocytal growths. In lymphatic leuchaemia there is a great 
increase in the number of small mononucleated leucocytes (lym- 
phocytes) present in the blood, and there is some enlargement 
of the lymphatic glands. Leuchaemic patients are liable to attacks 
of pyrexia the cause of which is not explained. The prognosis 
is unfavorable, death being brought about by progressive exhaustion 
during one of the attacks of pyrexia, or by dyspnoea. In the 
treatment, iron, arsenic, quinine, and the inhalation of oxygen have 
been recommended, but more is to be expected from placing the 
patient under the best possible hygienic conditions, and prescribing 
an outdoor life. 

The relation of Hodgkin's disease to the conditions already men- 
tioned is not clearly defined. It is a peculiar affection of the lym- 
phatic system, apparently ineifective, beginning locally but extending 
gradually to all lymphatic glands. In some cases the enlargement 
ensued upon a simple adenitis, but in others no such sequence of 
events can be traced. There is a hyperplasia of the lymphatic 



HAEMOPHILIA. 253 

glands, and nodules of lymphatic tissue may form eventually in other 
organs. The disease is rare, but about 1(5 per cent, of the cases oc- 
cur in children under ten years of age. The changes in the blood are 
not constant ; as a rule both red and white cells are diminished in num- 
ber, but there may be leucocytosis. The glands most often aifected 
at first are the cervical and those about the angle of the jaw, then 
the axillary. In these situations the enlargement may eventually 
produce very large tumors. The glands are at first distinct and 
easily movable, but after they have attained the size of a large almond 
they usually become fused together, forming large, solid, but not 
very hartl, tumors. When this stage is reached, suppuration may 
occur near the surface. The inguinal, the mediastinal, and the 
tracheo-bnmchial glands are involved usually after those of the up- 
per part of the body. The spleen is enlarged in three-fourths of the 
cases, and in more than half contains lymphoid tumors, which nuiy 
be present also in the liver and kidneys. Of the symptoms the most 
constant is fever, which, however, may be very irregular, ceasing for 
weeks at a time. In rare cases exacerbations and remissions alter- 
nate with regularity. Hiemic murmurs and palpitation of the heart 
occur in most rases, and shortness of breath maybe produced, either 
by the antemia or by the pressure of mediastinal glands. 

The diagnosis from tuberculous adenitis is often difficult at first. 
In Hodgkin's disease the enlargement is usually more or less sym- 
metrical, and the glands do not tend to suppurate until they have 
attained a large size. 

[The absolute diagnosis of Hodgkin's disease is impossible without 
a blood count. The symptoms may be those of leukoemia and the 
pathology in both diseases is the same. Examination of the blood is 
of value negatively, in showing the absence of leukaemia. The mye- 
locytes already mentioned as diagnostic of the splcno-incdidhu'if vari- 
iety of the latter, are absent or present only in small numbers. The 
lymphocytes, greatly increased in the lymphatic type of leukaemia, 
are not increased in Hodgkin's disease.] 

The prognosis is bad. As a rule the enlargement of the glands is 
progressive, and is attended by increasing antemia and by dropsy, 
the patient becomes extremely cachectic and succumbs to exhaustion. 

In the treatment of Hodgkin's disease the best results have been 
attained from arsenic in full doses, but phosphorus has also been 
reconimendfHl. 

Haemophilia is an hereditary disease characterized by a peculiar 
tendency to bleed either spontaneously or on slight injury. It af- 
fects mainly the male sex, but is transmitted by the female. Its 
pathology is unknown. One or more members of the same genera- 
ation may be affected, but seldom all the members of tiie family. 
The degree to which the tendency to haemorrhage is present varies in 



254 AN.EMIA AXD LEUCH^EMl A— HAEMOPHILIA. 

different bleeders, and in the same person at different times. When 
the tendency is well marked, a slight pressure or blow is followed h^ 
considerable haemorrhage into the cutaneous structures, and a large 
ecchymosis forms which passes through the regular phases of a 
bruise. A slight cut bleeds freely and continues to ooze for days ; 
the mucous membranes are easily provoked to bleed, and the extrac- 
tion of a tooth may be followed by serious and even fatal haemor- 
rhage. Bleeding from the nose is easily induced, and often difficult 
to arrest ; while vomiting is usually attended by haemorrhage from the 
stomach. Blood may appear in the urine without obvious cause. 
The most serious local results are seen in connection with the joints ; 
after some slight injury or strain, sometimes without any apparent 
cause, blood is rapidly effused, and the joint, usually the knee, be- 
comes distended and tender. The swelling subsides with rest, but is 
very apt to recur, and leads to thickening of the synovial membrane 
and distortion of the joint with permanent inability. In the same 
way, intracranial haemorrhage may occur and may cause sudden death. 
The disease usually manifests itself in the first year of life, some- 
times about the second dentition. The prognosis as to ultimate sur- 
vival is bad, as many of the patients succumb during childhood to 
some intercurrent malady which is aggravated by the tendency to 
bleed. 

In the treatment the main indication is to protect the patients 
from injury. Since the haemorrhage is almost exclusively capillary, 
ergot and other similar drugs are not likely to be of much service 
for the arrest of haemorrhage ; for this purpose pressure at the bleed- 
ing point is most to be trusted, and ^y right recommends the use of 
a tampon soaked in a one-per-cent. solution of calcium chloride, 
which produces a very firm clot. 



CHAPTER XXIL 

DISEASES OF THE THYROID AND THYMUS 
GLANDS. 

Acute Thyroiditis — Goitre — Cretinism — The Thymus Ghind ; Anatomy ; Thymic 
Asthma. 

THE THYROID GLAND. 

Acute thyroiditis is a very rare affection. It has been observed 
chietiy abont the age of puberty, but has also been met with in young 
children.^ It causes enlargement of the gland, which forms a swell- 
ing on each side of the neck and extending across the middle line. 
The swelling moves with deglutition, and is thus distinguished from 
that produced by lymphadenitis or subcutaneous phlegmon. The 
inflammation of the thyroid is accompanied by fever and causes some 
dysphagia, pain on movement, tenderness, enlargement of the veins 
of the neck, and slight cyanosis. The amount of dyspncea varies; 
in some cases it has been considerable, causing the head to be re- 
tracted. In most cases the swelling begins to subside in a few days, 
though some enlargement and hardness of the gland may persist for 
weeks. Such cases may, perhaps, be rheumatic in nature. In other 
cases, generally those in which the patient has been suffering from 
er\'sipelas, suppuration has occurred ; it is an occasional complication 
of typhus fever and pyjemia, and has also followed thyroiditis due 
to injury. The treatment of acute simple thyroiditis must be con- 
ducted on general principles ; if the enlargement of the gland be 
sufficiently great to produce symptoms of pressure on the larynx, 
leeches should be applied. The dyspncea has, in some cases, been so 
severe as to render tracheotomy, or division of the thyroid isthmus, 
imjx'rative. 

Goitre may be congenital, and is then due to hyperplasia of 
glandular and interstitial substance. It is seldom met with except 
in goitrous localities. At a later age cystic bronrhocele is not very 
uncommon in certain districts. Exophthalmic goitre has been ob- 

rvffl in (liildhoocl, but is an exceeding rare affection at tiiat age. 

Cretinism is a condition of defective development of Ixxly and 

'Barlow {IVans. Clin. Soc., vol. xxi., p. 67) has recorded a case in a boy aged 3 
yeare. His paper contains an analysis of the literature. 

255 



256 DISEASES OF THE THYROID AND THYMUS GLANDS 

mind due to the absence of the thyroid secretion, owing to want of 
development of the gland or to its atrophy in early life. 

Sporadic cases occur in most civilized countries, and are not un- 
common in London. The degree to which the arrest of develop- 
ment is carried, and to which the special characters are produced, 
varies in different cases in dependence, probably, on the date at 
which the atrophy of the gland occurs and the degree to which it is 
carried. The body is dwarfed, and the mind also. The appearance 
is characteristic. The face is broad and pale ; the lips heavy ; the 
eyelids thick, so that the palpebral aperture is narrow. The 



Fig. 24. 





Acquired cretinism, a, The patient is stated to have developed normally until the age of 5 years, 
when she had a severe attack of scarlet fever, after which growth nearly ceased, and a great change 
came over her mental state. At the age of 18% years, when the photograph was taken for me by 
Dr. George W. B. Waters, she was childish, showed no signs of puberty, and was slow in move- 
ments and in speech. Her height was 44 inches, and her weight 48 lbs. The average height of a 
girl of 18 years is 62.5 inches, and the average weight 117.7 lbs. The average height of a girl aged 
5 to 6 years is 40.8 inches, the average weight .39.6 lbs. (see page 3). b, The same patient four 
months later, showing some improvement in the intelligence of her expression— there had also 
been some increase in height— after treatment by thyroid extract. 



tongue is large, and may be so much hypertrophied (macroglossia) 
that it cannot be withdrawn between the lips ; the body is clumsy ; 
the hands are broad and fin-like ; the feet large and flat ; the skin 
is dry and harsh ; the hair thin and lustreless. Above and im- 
mediately below the clavicles there are, in many cases, masses of 
subcutaneous fat. The gait is clumsy, and the movements of the 



CRETIXISM. 



257 



hands slow aiul awkward. The extremities are cohi. The intelli- 
gence and general condition of the patients are worse in winter. The 
arrest of physical and mental development may be snch that a cretin 
of twenty years is no bigger than a child of three, is an idiot and 
unable to speak, and must be fed and dressed. In milder cases 
gro\N'th of body and mind is retarded, but not completely arrested. 



Fig. 2- 




Congenital creiinisiu, showing an extreme degree of the condition. The patient wa.s a girl aged 
18 years at the time the photograph wa.s taken ; the stupid nmbecile) expression, the large tongue, 
olavicalar masses of fat, and general stunting of growth are well seen. 



A cretinous girl of nineteen, for instance, had the aspect of a dull 
child of nine or ten ; she stood 3 ft. 8 in., could sjieak in a slow, 
monotonous voice, and could do a little house work (Fig. 24). The 
age at which the defect in the bodily and mental de\'elopment of 
the child is first noticed varies, but the aspect may be quite charac- 
17 



258 DISEASES OF THE THYROID AND THYMUS GLANDS, 

teristic before or soon after the child has completed its first year 
(Fig. 25). 

The diagnosis^ owing to the dwarfing of the body, the condition 
of the skin, the cervical lipomata, and the aspect of the face, is 

FiCr. 26. 




Congenital cretinism. The same patient as Fig. 25 after treatment for six months with thyroid 
extract. (Dr. W. Rushton Parker's case ; the history of the patient is related in the Brit. Med, 
Journ., 1896, vol. i., 1350.) 



usually easy ; but in infancy and early childhood it may sometimes 
be difficult to feel certain that the mental deficiency may not 
own another cause. The type of idiocy commonly spoken of as 
Mongolian, illustrated in Chapter XLL, presents a considerable 
resemblance to cretinism. Growth is stunted, the expression dull, 



CRETIXISM. 



259 



the mouth open, the tougiio often hu*ge, the movements nncertain, 
and speech, which is acquired hite, is moiiosyHabic. The skin is 
coai-se, the subcutaneous tissues are thick, and marginal blepharitis 



Fu;. 




"Adolescent" cretin, aged 22 years, after treatment for three and a half years with thyroid 
extract, showing bending of leg-bones, comparative growth of arms and legs, and alteration in 
! of hands. (From a photograph by permission of Dr. John Thomson. ) 



is very common. Lipomata do not occur, the slowness of intellect 
m infancy is less marked, mf>vements are usually quirk and jerky, 
and bodily development though -low i< not arrested as in well-marked 
congenital cretinism. 



260 DISEASES OF THE THYROID AND THYMUS GLANDS. 

[The condition known as foetal rickets achondroplasia or the chon- 
drodystrophia foetalis, is liable to be mistaken for cretinism. Osler^ 
reports the following 2 cases : 

" The parents were healthy French Canadians. There were 
fourteen children in the family, the eldest twenty-seven, the 
youngest four. Five children had died in infancy. With the 
exception of the dwarfs, the children were all very healthy and 
well grown. 

"Wilhelmine C, aged sixteen years, height 86.5 cm. (34 inches) 
(Fig. 28). The mother did not remember anything abnormal 
about her as a young infant. She walked w^hen eighteen months 
old. The head seemed large, and the mother said that the fontanelle 
did not close until the sixth year. When between three and four it 
was noticed that she did not develop naturally, and that the joints 
were very large. She is bright looking and intelligent, but some- 
what full and coarse-featured. The head measures 56 cm. The 



Fig. 28. 



Fig. 29. 





teeth are well formed. She talks fluently and well, and has learned 
to read a little, and is beginning to write, but she is backward for 
a girl of her age. The most remarkable phenomenon is the con- 
dition of the joints of the long bones. The shafts are short and 
look thin, and the articulations are very large and irregular. The 
shoulders are not much affected, but the elbow-joints, the wrist- 
joints, and the knees and ankles are enormously enlarged. She is 

^ Osier : Sporadic Cretinism in America. ( The American Journal of the Medical 
Sciences, Vol. CXIV., No. 4.) 



CRETISISM. 261 

a little knock-kneed when she stands. The mobility in the joints 
is perfect. 

"Alphonse C, aged eleven and a half years, height 87 cm. (33 J 
inches) (Fig. 29). The mother did not notice anything special 
about him except that he was late in walking, and the anterior 
fontanelle did not close until between the third and fourth years. 
He did m^t seem to gnnv much after the fourth year. He pre- 
sents an identical picture to that of his sister. His head is large, 
but well formed. He is very intelligent looking and bright, and 
is good tempered. The articulations are extraordinarily large, 
and contrast with the smallness and shortness of the shafts of the 
bones. He is somewhat pigeon-breasted, and when he stands is 
knock-kneed. 

^^The trunk and head in both these children look almost of natural 
size, but the shortness of the legs, and particularly the shortness of 
the shafts of the long bones, is very striking. The thyroid gland 
was not enlarged in either case. 

'' The relation of this remarkable condition to cretinism is very 
carefully discussed by Kaufmann,^ and more recently by Bircher,^ 
to whose papers the reader is referred. John Thomson, in the 
Edinburgh Medical Jonrndl for 1893, gives excellent illustrations 
of the adult form.^ The thyroid is not usually involved, though 
it has been found absent in a foetus which presented this condi- 
tion (Bowlby).^^ The intelligence is not specially disturbed, the 
facial and cranial characters are not those of cretinism, and myxoe- 
dema is not present. The most characteristic feature is the dwarf- 
ing, with remarkable shortness of the limbs (micromelia), owing 
to disturbance of the growth of the shafts of the long bones, and 
with, in most cases, enormous enlargement of the articulations, due 
to a hy}>erplasia of the cartilaginous ends of the bones. Bircher 
concludes that the condition is quite independent of the state of the 
thyroid gland. He is in error, however, when he states that the 
cases of sporadic cretinism described by Gushing and Fagge belong 
to this group."] 

TrecUment by the administration of thyroid gland should be resorted 
iM in every case in which any douljt exists, since it produces distinct 
amelioration in cretinism, and slight improvement in ^longolian 
idiocy. The cxpfricnce of most observers proV)ably agrees with that 
of Byron Bramwell, ' who points out that most cases of si)oradic cret- 
inism are very susceptible to the action of thyroid extract. A small 

' Unter^uchunjfen die iiber sogenannte foetale Rachitis (Chondrodystrophia Foe- 
talij). Berlin, 18H2. 

» LubarK-h und Ostertair, Erpebiiissc, Abt. i., IJ^OO. 

'They are reprrxluce^l in ^iould and Pyle's "Anomalies," etc. 

* Pathological Society Transactions, 1884. 

^ EfUnhurrjh Ho^pitfJ Rfjtfjrt», vol. iii., p. 116. 



262 DISEASES OF THE THYROID AND THYMUS GLANDS. 



dose should be administered at first, gr. j to ij (a quarter of an average 
sheep's thyroid). In a cretin even this small dose may produce a 
series of symptoms to which the term acute thyroidlsm has been ap- 
plied — gastro-intestinal disturbance (furred tongue, vomiting, diar- 
rhoea), prostration, sweating, headache, myalgia, flushing, and feelings 
of discomfort. The patient should be kept at rest, and even in bed 
for the first week of the treatment, but after a time the susceptibility 
diminishes, and the dose may be increased cautiously until 5 grains 
are taken daily. The improvement in the general, but especially in 
the mental, condition is very remarkable, though the change is less 
rapid and striking than in the myxoedema of adults (Fig. 26). The 
treatment must be continuous, but after the maximum dose has been 
taken for two or three months, it may be reduced, the condition of 
the patient being carefully watched for any signs of deterioration. 
How far a cretin may be brought towards a normal standard of de- 
velopment cannot at present be stated ; but experience seems to show 
that relatively slight improvement only must be looked for, unless 
the treatment be commenced when the child is yet young. Early 
diagnosis therefore is a matter of great importance. In cretins, es- 
pecially those in whom a certain amount of development occurs dur- 
ing the early years of life, lateral curvature is not uncommonly ob- 
served, and one of the most disagreeable results of thyroid treatment 



Fig. 30. 



Fig. 31. 








; 




m 



is that during the process of growth which it stimulates, this lateral 
curvature is very apt to increase and to cause much aching pain in 
the part. This may be to some extent combated by gymnastic ex- 
ercises, but other bony deformities may occur, due to thickening and 



CBETINISM. 



263 



softening — apparently of a rickety nature — of the bones of the ex- 
tremities ^ (Fig- -T). It may therefore be necessary to keep the 
patient recumbent, and even to apply splints for some months, while 
the effect of the treatment by thyroid is producing its maximum 
effect. 

[Osier's " series of cretins illustrate so well the characteristic ap- 
pearance of the condition and especially the effects of thyroid treat- 
ment that it is reproduced here. " Fig. 30 presents a typical 
picture of a sporadic cretin, aged seventeen years, under the care 
of Dr. J. C. Caisson, of Syracuse, New York. Fig. 30 was taken 
a vear before treatment and Fig. 31 illustrates the condition a year 
at\er." 

Fig. 32 represents a girl, Theophilia P., aged two years, admitted 
to the Johns Hopkins Hospital, December 18, 1895. Mother a 



Fig. 32. 



Fig. 33. 



b 




Pole, no goitre in the family. Child presents the typical aspect of 
infantile myxredema. The thyroid gland can be felt and seems a 
little large. She can neither sit nor stand ; is pale, the skin of the 
face having a sallow waxy appearance. Tongue is large and held 
out all the time. The expression of the face is dull and idiotic. 
Puffiness and myxcedematous character of the skin of both hands 



'See a paper by Dr. .John Thomson, Brit. Med. Jour., 189G, vol. ii., p. G18, and 
the discuaeion thereon. 
' Osier : loc. cit. 



264 DISEASES OF THE THYROID AND THYMUS GLANDS. 






and face. The head measures 45 cm. in circumference, 25J cm, 1 1 
in the transverse, and 35 cm. in the antero-posterior. The an- 
terior fontanelle is large, almost as much so as at birth. Child's 



Fig. 34. 




\, ||f ; -1^^. 



Fig. 35. 







length on admission was 65 cm. The blood-count gave 4,648,000 
red corpuscles, 80 per cent, of haemoglobin, and about 11,000 
leucocytes. 

Fig. 37. 



Fig. 36. 





•*^^-- -'U^^^ 



On December 20th she was placed on the thyroid extract prepared 
by Dr. Abel. On beginning the treatment she weighed twenty 
pounds. Within two months, as illustrated in Fig. 33, the condition 



Cr.ETiyiSM. 265 

improved remarkably. She took an interest in snrrounding objects. 
The eyes had become bright and intelligent ; the pnffiness of the 
face and hands had almost wholly gone. As shown in the photo- 

Fu;. 3S. Fig. 39. 




r 




graph, the palpebral orifices had become nuich larger. The tongne 
was not held ont so far from the month, and the drooHng had ahiiost 
ceased. She remained in the hospital nntil September 1, 1(S96. 
The myxcedematous condition disappeared entirely, she gained eight 

Fig. 40. Fig. 41. 



a 







pounds in weight, and had thriven in every way. It is interesting 

to note in this case that from March 20th to April 4th, the child rc- 

I ceived no thyroid extract. She had had a little fever and bronchitis, 



266 DISEASES OF THE THYROID AND THYMUS GLANDS. 

and it was stopped. On the latter date it was noticed that the skin 
had become harsh and dry, the eyelids more puffy, and the child did 
not seem nearly so well. 

" Fig. 34 shows the patient of Dr. Eisner, of Syracuse, New York. 
The child was eighteen months old at the beginning of treatment, 
and the photograph shows a very characteristic state of infantile myx- 
oedema. Fig. 35 shows the state thirteen months after treatment." 

^^Figs. 36 and 37 illustrate the case of Dr. Yinke, of St. Charles, 
Mo., a boy, aged six years. Fig. 37 shows the condition five months 
after treatment. In a year and a half he grew nine inches.'^ 



Fig. 42. 



Fig. 43. 



/ 





If* ,.• 



\ ^^rV 




v^^ 



" Figs. 38 and 39 show a patient of Dr. Dickson L. Moore, of 
Columbus, Ohio, a girl, aged nine years. The treatment was begun 
August 12, 1896. Fig. 39 shows the condition seven months later, 
March 20, 1897. The child had gained four inches in height, and 
the entire appearance had changed remarkably." 

" Figs. 40 and 41 show a sporadic cretin at the age of thirty 
years, patient of Dr. Sinkler. The height was 112f cm. Fig. 41 
shows the condition a year after treatment. She had grown nearly 
7 cm., and had lost much of the myxoedematous characters. This 



CRETINISM. 



267 



case is of special interest as showing the importance of the treatment 
even in adults." 

''I know of no single set of photographs which show in quite the 
same way the phenomenal change as in this series of pictures very 
kindly sent by Dr. Coyner, of Peoria, 111. 

'' Figs. 42 and 43 show the very characteristic appearance of a spo- 
radic cretin, aged twenty-three months, length '28 inches, circumfer- 
ence of the abdomen 19 inches. Fig. 44 shows the change after three 
mouths' treatment ; the abdomen measured 16 inches. Fig. 45 illus- 



FiG. 44. 



Fig. 45. 




trates the condition after five and a half months' treatment ; height 
30 inches ; abdomen measured lo inches. Fig. 46 shows the change 
after seven and a half months' treatment ; while the last picture, Fig. 
47, shows eleven months after beginning the use of the thyroid a 
I>erfectly-natural looking child."] 

The Thymus Gland. 

The large size of the thymus gland at birth is one of the most 
striking features of the infantile thorax.' 

' Ballantrne, " Introd. to the Diaeases of Infancy," Etlinburgh, 1891, p. CI. 



268 DISEASES OF THE THYROID AND THYMUS GLANDS. 



It occupies the anterior mediastinum, lying behind the manubrium 
and the upper part of the body of the sternum, and the three upper 
costal cartilages. Its upper border projects above the suprasternal 
notch, and almost touches the isthmus of the thyroid. It varies £| 
good deal in size at birth, but the maximum measurements are abou 

Fig. 47. 



Fig. 46. 





as follows : — breadth, 3.5 cm. (IJ in.); length, 5 cm. (2 in. nearly) ; 
thickness, 2.5 cm. (1 in. nearly). It begins to atrophy about the 
end of the second year, undergoing fatty and fibrous changes which 
are usually complete about the tenth year. In infancy it produces 
an area of diminished resonance on percussion which may extend as 
low as the level of the third rib. 

Neither the functions nor the pathology of the gland are well un- 
derstood ; in syphilis it may be the seat of multiple abscesses, and 
tuberculosis of other organs may be accompanied by caseous masses 
in the thymus. It has long been supposed that the gland, if enlarged. 



THE THYMUS OLAND. 269 

might produce dyspna^a, and attacks attributed to this cause liave 
been called thymic asthma. Though this view has been contro- 
verted, there can ntnv be little doubt that enlargement — it appears to 
be due to general hyperplasia — may occur in infiuicy and early child- 
hcK>d. The enlargement makes itself evident by pnKlucing severe 
attacks of dyspnoea, due probably to sudden hypenemia of the glands 
In some cases the first attack of dyspnani is fatal. The ehdd in the 
midst of apparent health, sometimes on awakening from a sound and 
natural sleep, is seized with the most intense dyspncea, and dies 
asphyxiated before assistance can be rendered. In other cases dysp- 
ncea develops more gradually and becomes constant, though liable to 
temjwrary aggravation. In such cases tracheotomy has sometimes 
faileil to ffive relief until a tube of unusual lentjth has been inserted 
into the trachea. 



CHAPTER XXIII. 
DISEASES OF THE HEAKT. 

[Normal Position of the Heart] — Congenital Affections of the Heart — Pericarditis 
— Pleuro-pericarditis — Acute Endocarditis ; Simple ; Malignant — Chronic En- 
docarditis — Valvular Disease. 

[Normal Condition of the Heart in Infancy and Childhood. — 

A knoAvledge of the position of the heart and of its relation to the 
chest-wall in infancy and childhood is essential to a thorough grasp 
of the abnormal condition of this organ. In infancy the heart is or- 
dinarily more horizontally placed than it is in the adult ; hence we 
see the apex-beat higher and further to the left. With the growth 
of the child, this relation of apex-beat to chest-wall varies, owing 
partly to changes in position of the heart itself. As a result, the 
apex-beat swings downwards and inwards and consequently will be 
found in diiferent positions at different ages. Thus up to about the 
third or fourth year, it is outside the mamillary line, and in the fourth 
space. 

From the fourth to the eighth or ninth years it is in or near the 
mamillary line and generally in the fourth space, but occasionally in 
the fifth. About the eleventh to the thirteenth year we find it in 
the adult position, the fifth space quarter to half an inch inside the 
nipple-line. 

The upper limit of ^^ absolute dulness ^^ in infancy is at the fourth 
rib ; at six years is at the lower border of the third rib, and at ten 
or twelve years the upper border of the third rib, or sometimes as 
high as the second intercostal space. The right limit of dulness is 
the left para-sternal line. 

It is important to bear in mind these different boundaries, as fail- 
ures so to do may lead to erroneous deductions from the results of 
physical examination of the chest. It is also important to remember 
the thinness of the chest-wall in childhood and the consequent ease 
with which sounds are diffused throughout the thorax.] 

Congenital affections of the heart are due to defects of develop- 
ment, to foetal endocarditis, or to a combination of these two condi- 
tions. The more extreme deformities are incompatible with extra- 
uterine life. 

The changes in the valves produced by foetal endocarditis are usually 

270 



COXGEXITAL AFFECTIOXS OF THE HEART. 271 

indurative, the valves being thickened, irregular at the edges, and 
sometimes adherent. Thus two of the pulmonary valves may be 
adherent, so that the oritice has but two valves, or all three valves 
may be so welded together as to form a diaphragm with a single 
aperture. The auriculo-ventricular valves may be distorted and ad- 
herent to each other, and the chorda? tendinea^ thickened and short- 
ened. Fa^tal endocarditis atiects usually the right side. 

The abnormalities compatible with life for at least some years may 
be divided into those affecting the septa and the orifices. 

The auricula r .'icpfum may be defective owing to (1) the existence 
of minute perforations in the valve of the foramen ovale, or (2) to the 
failure of this valve to become attached along the whole of its mar- 
gin, so that a slit is left. Neither of these conditions necessarily in- 
terferes with the cardiac function. When the defect in the foramen 
ovale is considerable, a loud systolic murmur is produced, which is 
heard l)est at the base of the heart in front, but is audible also at the 
back. Children with this defect are very liable to bronchitis, which 
is attended by much embarrassment of the circulation. A defect in 
the ventricular septum is associated usually with some other congenital 
abnormalitv, esix^cially obstruction at the pulmonary orifice. The 
defect occurs usually at the base in the " undefended spot," the mem- 
branous space between the mitral and tricuspid valves. This defect 
produces a loud murmur replacing the first sound, heard best over 
the lower part of the sternum, but also in the axilla and back. 

Abnormalities at the puhnonanj orifice constitute 8G per cent, of all 
cases of congenital heart disease which survive^ beyond the age of 
twelve years. The commonest condition is stenosis, produced by a 
blending of the valves into a single membrane with an orifice which 
may be very small. In some cases there is obvious evidence of en- 
docarditis, but in others the diaphragm is smooth and thin, the ab- 
normality being due, apparently, to a developmental defect. It is 
associated usually with imperfect closure of the ventricular septum ; 
the condition is not incompatible with survival to adult age. The 
physical signs produce<:l are a loud systolic murnuir and feeble second 
sound in the pulmonary area ; but if the ventricular septum be also 
deficient a systolic bruit is heard at the lower part of the sternum. 
A more serious grade of pulmonary obstruction occurs when there is 
also narrowing of the conu^ arteriosuj< of the right ventricle, which is 
associated with imperfection of the ventricular sei)tum and patency of 
the foramen ovale and ductus arteriosus. Finally, associated with 
the defects just enumerated, there may l)c complete obliteration of the 
pulmonary- orifice, a condition incompatible witli long life. 

Congenital affections of the aorfir orifice are rare. The commonest 
form is that in which the number of valves is reduced to two by a 
blending of two valves, due to endocarditis shortly before birth. 



272 DISEASES OF THE HEART. 

Possibly in some instances, the defect is produced by developmental 
abnormality, but in either alternative the valves are very liable to 
become the seat of endocarditis after birth. 

Of the symptoms of congenital heart disease, the most striking is 
cyanosis, whence the name morbus cseruleus applied to the condition. 
It is absent in only 10 per cent, of all cases, but its intensity varies 
and it is always increased by crying or exertion. Lividity is noticed 
usually during the first few weeks of life. The nose, ears, lips, 
fingers, and toes have a purplish tinge, while the rest of the surface 
has a dusky tint. Cyanosis is most marked and most extensive in 
obliteration of the pulmonary orifice with patent foramen ovale. It 
is due to deficient aeration of the blood, which contains a very high 
proportion of red cells. Children presenting cyanosis do not thrive 
well, and are usually backward in intelligence. They feel the cold 
much, are very liable to bronchitis, and after a time the fingers and 
toes become clubbed. There is always some dyspnoea on exertion. 
They are liable also to attacks of dyspnoea without apparent cause. 
Death may ensue in one of these attacks. More often it is brought 
about by bronchitis ; but it should be noticed that a considerable 
number of cases die of intracranial abscess. 

The diagnosis of congenital heart disease is usually easy, owing to 
the co-existence of cyanosis and cardiac murmur. However loud the 
murmur, there is no thrill. In doubtful cases considerable increase 
of dulness to the right without signs of cardiac failure would favor 
the diagnosis of congenital disorder. Patent ductus arteriosus causes 
a loud vibrating systolic bruit, best heard over the upper part of the 
sternum. It is not accompanied by hypertrophy of the left ventricle, 
as is disease of the aortic orifice, but patency of the ventricular system 
may be attended by considerable hypertrophy of the left ventricle. 
In congenital heart disease without urgent symptoms treatment can do 
little beyond guarding the patient against bronchitis, and placing him 
in the best hygienic conditions obtainable. It should be borne in mind 
'also that children with congenital defects at the pulmonary orifice 
appear to be particularly liable to pulmonary tuberculosis. Cyanosis 
and dyspnoea will be relieved by the use of saline laxatives, and in 
the severe dyspnoeal attacks venesection is justifiable. The routine 
use of digitalis is to be condemned, but it may be valuable when 
there are signs of cardiac failure. 

Pericarditis. — Inflammation of the pericardium is usually sec- 
ondary to, or a part of a more widespread infective process. The 
commonest cause in children over three years of age is the rheumatic 
state of which pericarditis may be the first, or, at a particular time, 
the only manifestation. It occurs in about one-fourth of the fatal 
cases of chorea. It may be a complication of various acute infectious 
fevers, especially scarlet fever, but also, though more rarely, of 



PERICARDITIS. 273 

measles, small-pox, influenza, diphtheria, and enteric fever. It may 
be produced also by tuberculosis, by septicivniia, and in the course 
of acute Bright's disease. It may be determined by extension from 
pleuro-pneumonia, and this is probably the commonest cause in 
children under three years, though septic }>ericarditis associated with 
inflammation of the navel occurs sometimes in infants duriug the 
first weeks of life. Its occurrence before birth has been recorded. 
Acute jx^ricarditis is attended by the formation of fibrinous exuda- 
tion, but the amount of fluid eftused varies greatly. There may be 
little or no excess of fluid in the |x^ricardial cavity, and the quantity 
of plastic material on the surface varies from an amount sufficient 
only to produce a dulling of the serous surface to a thick membrane 
which has a corrugated or shaggy appearance. The pericarditis due 
to acute rheumatism is generally attended by eff'usion, the amount of 
which may be very considerable. In rheumatism, and in tubercu- 
losis, and septicaemia at firet, it is serous, but often contains shreds 
of fibrin whicli may form a thick layer on the serous surface. It 
contains, sometimes, a larger number of corpuscles, and is then 
opalescent or sero-purulent. Tuberculosis produces in time a ragged 
gray or yellowish false membrane, with thick, creamy pus m the 
pericardial cavity. In severe cases of pericarditis the myocardium 
is inflamed for a varying depth, and endocarditis is a common accom- 
paniment, though seldom due to direct extension. 

The symptoms are often very indefinite, especially in young chil- 
dren. Tliere is usually pain referred to the prjecordia or to the 
epigastrium, and there may be some tenderness in these situations. 
When pericarditis occurs as a primary affection its onset is attended 
usually by chilliness, or shivering, and some elevation of temperature, 
but it may be very insidious. The child is noticed to be indisposed 
to play, short of breath and pale for a week or two before it is brought 
for treatment. Then, perhaps, a large effusion is found, or a cliar- 
acteristic friction sound. Considerable efliision with a very insidious 
onset should lead to a suspicion of tuberculosis. In the dry form 
the physical signs are those produced by the rubbing together (►f tlie 
roughened pericardial surfaces. Fremitus may be felt over the right 
ventricle, and on auscultation a double to-and-fro friction sound. 
This corresponds with the systole and diastole of the heart, and is 
rough and grating, f»r resembles that produced by new leather. It 
is audible most often at the base or in the fourth space (over the right 
ventricle), more rarely at the apex. It is heard usually over a ver\' 
limited area, but may be conducted for some distance down the ster- 
num. It is not constant in intensity, and may be abolished by 
effusion. In dr}* pleurisy alsf» it may disappear owing, ])ossibly, to 
the formations of ndlip-ion-. but it reappears if tlic inflammation 
X tends. 
18 



274 DISEASES OF THE HEART. 

The diagnosis, when pericarditis occurs as a complication of acute 
rheumatism Avhile the patient is under observation, is comparatively 
easy, since the changes in the physical signs are characteristic. But 
in cases with an insidious onset it may be difficult. Thus friction at 
the base may suggest a diagnosis of aortic incompetence, but the 
limited area over which the double murmur is heard is peculiar, and 
the harsh rubbing character and the absence of the characteristic 
modification of the pulse will generally permit a diagnosis to be made 
with confidence. Friction is occasionally due to pleuro-pericarditis 
(see below). Dry or plastic pleurisy may be succeeded by effusion, 
or it may end in the production of more or less extensive adhesions. 

If pericarditis produces considerable effusion, the symptoms and 
physical signs are much more distinctive. There is usually a good 
deal of pain referred often to the epigastrium and aggravated by 
pressure. The face is anxious and dusky, the patient lies on the 
left side, or sits up, and is breathless on slight exertion. The pulse 
is rapid, and at the wrist may be very weak or disappear altogether 
with each inspiration — pulsus paradoxus. Cough is often trouble- 
some, and dysphagia may be present. These symptoms are to be 
attributed to the embarrassment of the circulation, and are attended 
usually by nervous depression, which, in later stages, gives way to 
restlessness and insomnia, to delirium, and, finally, to coma. The 
physical signs vary w^th the degree of effusion — bulging of the 
prsecordia, fulness of the intercostal spaces, and oedema of the skin 
may be marked in children, even at an early stage ; and after a time 
considerable enlargement of the lower part of the front of the chest 
on the left side may be produced. Expansion of the left side is 
diminished owing to compression of the left lung. The apex-beat 
is displaced upwards and outwards, and becomes weaker and finally 
disappears as the effusion progresses, though it may generally be 
perceived if the patient bends forward or lies on the face. On per- 
cussion the area of dulness is increased, both upwards and over the 
sternum. The dull area has an irregular pyramidal shape. Much 
importance has been attributed to disappearance of resonance in the 
fifth interspace on the right side ; this may occur even early in peri- 
carditis with effusion. It may also be observed in dilatation of the 
right ventricle. The dulness may extend upward into the second 
and even into the first interspace on the left side. The upper limit 
may vary from time to time, the variations depending, in part, on 
the quantity of fluid, but probably, in part, also, on the degree to 
which the pericardial sac gives way under the pressure. 

Displacement and depression of the left lung cause the percussion 
note in the axilla below the nipple line to become flat or tympanitic. 
As the amount of fluid increases, the to-and-fro friction sound 
diminishes and may eventually disappear ; on the other hand, it may 



FEBfCARDITIS. 275 

}H'i*sist at the base, so that the existence of friction does not disprove 
the presence of a htrge amount of fluid. The heart sounds grow 
weaker and more distant as effusion increases. The course of the 
affection is very variable ; rapid effusion is often followed by rapid 
absorption. In septicfcmic pericarditis pus is rapidly formed, and 
early death is the rule. In the more chronic cases the pus may 
point near the sternum. 

Tlie diagnosis of effusion may be dillicult if the case cannot be 
watched from the first. If very large, it may be mistaken for 
effusion into the left pleura, but the situation of the dulness and the 
mutfled character of the heart sounds, as well as the position and 
the character of the ajx^x-beat, will generally prevent error. From 
dilatation of the heart the diagnosis of effusion into the pericardium 
may be very dillicult, and mistakes have been made by the most 
careful. In dilatation the impulse is wavy, and visible usually in 
several spaces ; the shock is more distinct ; the sounds clearer, being 
ften very sharp and ringing ; the area of dulness is not pyramidal, 
and does not rise above the third space ; and there is no tympanitic 
note in the axilla. 

Aflhc'iion of the two surfaces of the pericardium is a common 
consetiuence of pericarditis. Kheumatic pericarditis may lead to 
: few scattered adhesions, especially over the right ventricle, or to 
more extensive and even universal adhesions. In adherent pericar- 
dium from this cause the thickening is not great, and tlie adhesions 
are fibrous ; but in tuberculous pericarditis there may be great 
thickening with caseous nodules in the substance. Small, limited 
adhesions give rise to no symptoms or physical signs. A\ hen ex- 
tensive or universal, more or less cardiac hypertrophy ensues. There 
is often considerable bulging on the left side in front, so that the de- 
formity of the chest is obvious at the first glance. The area over 
which the cardiac impulse is felt extends downwards to the sixth 
-pace and outwards beyond the nipple. The maximum impulse is 
usually a go<xl deal to the right of the apex, and a characteristic sign 
when present is a retraction at the apex or lower sternal region with 
stole, and a rapid rebound during diastole (diastolic shock, with 
'llapse of the cervical veins). 
[Another sign which according to Osier is of diagnostic value is 
that knr>wn as " Broadbent's sign." This consists in a systolic rc- 
tmction in the line of attachment of the diaphragm from behind, in 
ell-marked instances seen on both sides, often only on one side and 
II only one interspace, the 10th or 11th. Broadbent attributes this 
ign to broad adhesions between the right ventricle and the dia- 
phragm as a result of which there is a systolic tugging at tlio dia- 
phragm with a consequent retraction of the chest-wall.] 

The area of absolute dulness is usually considerably increased. 



276 DISEASES OF THE HEART. 

There may be no murmur, though a systolic bruit at the apex is the 
rule. 

In the treatment of acute pericarditis the most important element 
is rest in bed. When the symptoms are severe, an ice-bag should be 
applied over the prsecordium. It should be used on the first occasion 
for about an hour, then for two hours, and, finally, should the symp- 
toms persist, it may be applied continuously. E'or the relief of pain 
and irritability morphia may be necessary. In less severe cases dry 
or, in robust children, wet cupping may be sufficient. A small 
mustard poultice will often have the same effect, but there is the ob- 
jection to its use that it interferes with subsequent applications, and 
hot fomentations or poultices are preferable, especially in young 
children. In rheumatic cases the salicylates will be used, but their 
influence over pericarditis is not very marked. It is doubtful 
whether potassium iodide hastens the absorption of fluid, and its 
depressing effect is undesirable. With rest and careful nursing the 
fluid, as a rule, disappears spontaneously. When a rapid and copious 
effusion is threatening life, it is justifiable to tap the pericardial sac. 
The point selected should be the fourth space, one inch to the left of 
the sternal margin, or in the fifth space a little farther out. [Rotch's 
researches have shown the greater safety of tapping in the fifth right 
interspace. We thus avoid the heart and are sure of striking the 
fluid even though it be small in amount.] If the effusion be very 
large, it has been recommended to insert the needle in the costo- 
xiphoid angle, close to the costal margin, and to push it upwards and 
backwards. If the fluid be purulent, incision and drainage appear 
to be the most rational treatment. 

Ashby has applied the term pleuro-pericarditis to a rare condition, 
the exact nature of which is somewhat obscure. As Osier has ob- 
served : ^^ In children chronic adhesive pericarditis may be asso- 
ciated with proliferative peritonitis, perihepatitis, and perisplenitis, 
in which condition ascites may recur for months, or even for years.^' 
Ashby describes such a sequence of events as a consequence of 
inflammation of the serous membrane reflected over the anterior 
edges of the lungs, the only definite sign being a friction sound, 
synchronous with the cardiac beats, more intense during inspiration, 
and disappearing during expiration. Finally the edge of the lung 
becomes adherent to the pericardium. A subacute inflammatory 
process, which is in some cases tuberculous, may ensue in the me- 
diastinum (mediastino-pericarditis). The pressure upon the veins 
entering the chest leads to secondary fibrosis of the liver, and 
chronic ascites may be the most prominent symptom. The patient 
may live for long — until the portal obstruction becomes too great to 
be compatible with life. 

Endocarditis. — Inflammation of the lining membrane of the 



MALIGXAXT EyDOCARDITlS. 277 

heart is confined usually to the valves. It may be acute, with the 
production of vegetations, or loss of substance by ulceration, or 
chronic, and attended by sclerosis, with thickening and puckering. 

Two forms of acute endocarditis may be distinguished — simple 
and malignant — which ditier in the degree but not in the nature of 
the anatomical lesions. 

Acute Simple Endocarditis may occur at any age, and even be- 
fore birth, but it is very uncommon during the first two or three 
years of life. As in the adult, so in children simple endocarditis is 
more often due to the rheumatic poison than to any other cause. It 
may be at the time of its occurrence the only manifestation of the 
rheumatic state. Sometimes it occurs as a complication of erythema 
nodosum, peliosis rheumatica or acute tonsillitis, but usually it comes 
on during an attack of acute or subacute rheumatic arthritis. It is 
a not uncommon complication of scarlet fever, with or without ar- 
thritis, and of pneumonia. It is one of the rare complications of 
measles, small-pox, chicken-pox, diphtheria, and enteric fever. It 
is often present in chorea, and is found after death in the majority 
of all final cases. Recurrent or relapsing endocarditis — that is to 
say, acute inflammation grafted on the sclerotic condition produced 
by chronic or sclerosing endocarditis — yields perhaps the largest 
number of cases actually met with in practice. 

Malignant Endocarditis seldom, if ever, occurs as a primary 
disease in children. In them it is secondary most often to recurrent 
endocarditis, Init it may occur as a complication or sequela of vari- 
ous acute diseases, especially pneumonia, but also of rheumatism, 
septiciemia, erysipelas, gonorrhcea, and of acute osteo-myelitis or 
arthritis. It is said to be rare in chorea, but the most typical cases 
I have seen in children have been in sufferers from chronic relapsing 
endocarditis which originated during an attack of chorea. 

Morbid Anatomy. — Acute endocarditis is characterized by the 
pnKluction of vegetations on the valves, es}X?cially at their edges. 
They consist of granulation tissue, and have an irregular fissured 
surface coated with fibrin, in which micro-organisms may be demon- 
stral)le. The vegetations (1) may undergo resolution, a small nod- 
ular thickening of the valve remaining ; or (2) may increase in 
size, and then undergo disintegration and ulceration (malignant en- 
docarditis). The ulcerative ]U'ocess l)egins in the vegetati(»n, but 
may extend to the endocardium, producing a more or less extensive 
necrosis, which may cause perforation of a valve, of the septum, or 
even of the heart ; or suppuration may occur at the base of the 
vegetations, with the production of small abscesses. The vegeta- 
tions and ulcers contain various microbes — generally the sfrrjfforfimiM 
pyff^ffneHj or one of the staphylococci ; but the bacillus of typhoid, 
anthrax, and tubercle, the gonococcua and the micrococcuM /fntccolafiiXj 



278 DISEASES OF THE HEART. 

have also been met with. Except in foetal life, the left side of the 
heart is that usually affected, and when tlie right side is attacked it 
is due to secondary infection. Portions of the vegetations or of 
their fibrinous caps may be detached, forming emboli, which may 
become impacted in the spleen, kidneys, brain, intestines, or other 
organs. In malignant endocarditis these emboli, being infective, 
give rise to abscesses, and in some cases a very large number of 
minute abscesses may thus be produced. 

The symptoms of simple endocarditis are slight pyrexia, with in- 
creased rapidity and sometimes irregularity of the heart or palpita- 
tion. They coincide as a rule with the development of a soft mur- 
mur, usually at the apex which amounts at first to no more than a 
roughening of the first sound. Since, in the vast majority of cases, 
endocarditis occurs first during an attack of acute rheumatism or 
other acute disease, in the course of which a bruit cle souffle may be 
produced without endocarditis, it is obvious that the diagnosis must 
often be conjectural. The course of simple endocarditis is usually 
short, from a few days to a week or two. It may terminate in ap- 
parent recovery, but in a large proportion of cases more or less 
chronic sclerosing endocarditis ensues. 

The symptoms produced by malignant endocarditis, whether it be 
a complication of an acute infectious disease or secondary to chronic 
endocarditis, are usually of the typhoid type — prostration, somno- 
lence, muttering delirium, severe sweats, sometimes rigors, irregular 
temperature, and petechise or septic rashes. In a minority of cases 
the symptoms are distinctly pysemic, with marked rigors, profuse 
sweating, septic rashes, diarrhoea, and often jaundice. In either 
form the sudden onset of pain in the left side, the appearance of 
blood in the urine, or the development of hemiplegia may indicate 
the occurrence of embolism in the spleen, kidneys, or brain. The 
course of malignant endocarditis may be short, not more than a few 
days ; usually it is prolonged, especially in the cases which ensue 
upon recurrent endocarditis, and there may then be many remissions, 
followed by relapses. 

The diagnosis of malignant endocarditis is often difficult. When 
in the course of endocarditis the general constitutional symptoms be- 
come severe, with an irregular temperature, especially if rigors oc- 
cur, the supervention of malignant endocarditis may be assumed, 
and the diagnosis will be placed beyond doubt by the occurrence 
of suppuration in internal organs. Cases liable to be mistaken for 
typhoid fever occur in children probably less often than in adults ; 
distinctive points are the more abrupt onset, often with pain referred 
to the cardiac region, the irregular pyrexia from the first, rigors, 
and the early occurrence of dyspnoea. 

In the treatment of simple endocarditis, the most important indica- 



MITRAL ISCOMPETENCE. 279 

tion is rest in the recumbeut attitude, and it is vorv doubtful whether 
in cases of moderate severity, treatment bv drugs has any beneficial 
effect upon the course of the disease. The salicylates appear to 
exercise very little influence, and I have never seen any advantage 
result from the use of aconite. In severe cases the ice-bag may be 
of use. Small doses of opium relieve pain and quiet irregular car- 
diac action, and at later stages, if there be signs of cardiac failure, 
digitalis may be tried cautiously. If the endocarditis be complicated 
by pericarditis, the treatment should be directed to the relief of that 
condition. AVhen there is much excitement potassium bromide is 
the most innocuous sedative. The diet should be light, and should 
'>nsist chieflv of milk diluted with some slisrhtlv aerated water, 
given in small quantities. At the commencement of treatment the 
bowels should be unloaded, and for this purpose calomel is probably 
ihe best drug. Flatulent distension of the stomach or colon should 
be watched for and treated at once, since the embarrassment of the 
heart may thus be greatly increased. After recovery from the acute 
attack, great care is required for a long period. The child should 
be carefully clothed and dieted, and a boy ought not to go to a pub- 
lic school for at least a year. 

In malicrnant endocarditis verv little can be done, and nearlv all 
cases terminate fatally. The perchloride of iron in full doses is the 
drug from which most may be expected ; but its use may be com- 
bined with salicylates, or, perhaps, best with salol. 

Chronic endocarditis is in children probably always a sequel of 
acute endocarditis. There is a sclerosis of the valve, leading to 
thickening, and, o\^'ing to the contraction of the fibroid tissue, to 
puckering, which renders the valve insufficient. In many, perhaps 
in the majority, of cases even in children, the fibroid thickening and 
consequent contraction involves the bases of the valves, and leads to 
narrowing of the orifice. The physical signs and consequences vary 
accordingly to the valve involved and the nature of the changes pro- 
lucing it. 

The mitral is the valve most often diseased. 

Mitral incompetence, due to endocarditis, may be produced by 
distortion of tlie valve and retraction of the chorda? tendincje alone, but 
nay be accompanied by narrowing of the orifice. A relative mitral 
incrjmjx*tence without lesion of the valve may occur in fevers when 
the myocardium is weakened, in anaemia, or in dilatation from any 
ause. Permanent mitral incompetence throws increased work upon 
the left ventricle, and causes it to hypertrophy. Eventually it leads 
to dilatation of the pulmonary veins, arteries, and capiUaries, leading 
to brown induration of the lung, and finally to hypertrophy of the 
right ventricle. When the compensatory hypertrophy of the ven- 
tricles is insufficient, or when from any cause it fails, the engorge- 



280 DISEASES OF THE HEART. 

ment of the pulmonary circulation is increased^ and the growing em- 
barrassment of the right heart leads to incompetence of the tricuspid 
valve, engorgement of the systemic veins, congestion, especially of 
the portal system, and finally to dropsy. 

The symptoms, while compensation is maintained, are slight, but 
are usually more marked in children than adults. There is short- 
ness of breath on slight exertion, the face is congested or slightly 
cyanotic, and the cutaneous venules are enlarged. The patients are 
liable to bronchial catarrh, and the expectoration is often blood- 
stained, or distinct haemoptysis may occur. Complaint may be made 
of palpitation, or of uneasy sensations in the cardiac region, to be 
traced often to flatulence. The pulse is usually small and is often 
irregular, even with complete compensation. The physical signs vary 
with the degree of hypertrophy, with the length of time during which 
the condition has existed, and with the state of compensation. In 
children in whom the lesion has occurred at an early age, and has 
been followed by considerable hypertrophy, there may be very obvious 
bulging of the prsecordia. The apex-beat is displaced outwards and 
downwards towards the axilla ; it is strong and heaving if compensa- 
tion is good, but weak, wavy, and diffuse if it have broken down. 
The area of cardiac dulness is enlarged, chiefly downwards and to the 
left. The first sound is more or less completely replaced at the apex 
by a murmur, which is usually blowing and is conducted into the 
axilla, and may be heard at the back near the angle of the scapula. 
Its intensity may be altered by a change in the position of the patient ; 
thus it may be heard in the erect but not in the recumbent position, 
or vice versa. The second sound is accentuated in the pulmonary 
region (the second interspace or third cartilage). When compensa- 
tion gives way the action of the heart is weak and irregular, and the 
patient complains bitterly of being conscious of the heart's action, or 
of actual palpitation. Dyspncea on exertion becomes more severe, 
and finally is never absent, the patient being unable to lie down. 
The overfilling of the pulmonary vessels causes an oedematous condi- 
tion of the lung, determining cough and watery expectoration, often 
blood-stained. The overfilling of the systemic veins produces a 
cyanotic tint of the surface and cedema, generally beginning in the 
feet and ankles. The congestion of the portal system determines en- 
largement of the liver, gastric irritation, which often produces dis- 
tressing vomiting, and gastro-intestinal catarrh. The urine is scanty 
and often albuminous. When dilatation has occurred the bruit may 
be very much diminished in intensity, and a soft tricuspid murmur 
may be heard at the lower part of the sternum. 

Mitral stenosis is more common in females than in males. In rare 
cases it is congenital ; as a rule it is produced by rheumatic endo- 
carditis in early life. It is usually accompanied by some incompe- 



MITEAL ISCOMPETENCE. 281 

tence. The valves may be thiekened and so generally adherent that 
only a button-hole orifice is left, or, without much thickening, the 
valves may become adherent forming a funnel-shaped orifice. In 
rare cases, which are probably congenital, the valves may be little de- 
formed, but the orifice is narrowed. With the button-hole or funnel 
orifice the chordie tendineiv are shortened and distorted, or the mus- 
culi papillares are inserted directly into the valve. With this condi- 
tion there is much less hypertrophy of the left ventricle than in in- 
sufficiency. In consequence of the obstruction offered by the narrow 
orifice, the left auricle becomes dilated and hyjiertrophied, there is 
backing up in the pulmonary vessels, and eventually dilatation and 
hyjx'rtrophy of the right ventricle : finally when dilatation is in excess 
«^f hypertrophy incompetence of the tricuspid is produced, with the 

nsequences already mentioned. 

In young children the hypertrophy on the right side may ]>roduce 
prominence of the fifth and sixth left costal cartilages and the lower 
part of the sternum. The apex-beat is often difficult to localize, 
^-'^ing in reality under the sternum and produced by the right ven- 

icle. The most characteristic physical sign is a thrill felt in the 
Iburth or fifth left space over a limited area and immediately pre- 
ceding the impulse. The area of airdiac dulness may be little 
altered, or it may be possible to discover a slight increase to the 
right. When compensation is established, the pre-systolic bruit is 
heard, a short, rough sound running up to the first sound which is 
loud and thudding. The combination is difficult to describe, but is 
very characteristic and hardly to be mistaken. The pre-systolic 
bruit is heard over a limited area to the right of the apex, and is not 
conducted into the axilla. It may be preceded by a diastolic bruit 
which may occupy the whole of the interval, or may be confined to 
the first part of the interval, when it is sometimes spoken of as post- 
systolic. As a rule there is no systolic bruit, though in some cases 
there is a faint or even a loud systolic murmur. The second sound 
in the pulmonary area is accentuated. Later on insufficiency of the 
tricuspid valve may lead to the development of a soft systolic bruit 
to the right of the sternum. When compensation fails the pre-systolic 
thrill and murmur may disappear, though a faint diastolic or post- 
systolic murmur may remain. When com|X'nsation is perfect there 
are no symptoms, and the patient may even live an active life past 
middle age without being aware that the heart is diseased. There 

. however, a great liability to recurrent attacks of endocarditis, and 
iM embolism, which occurs more frequently in mitral stenosis than in 
any other form of heart disease. Obstruction at the mitral valve if 
developed in early ehildJKKKl interfere- with growth, and the patients 
are usually of small build, sometimes obviously stunted. When 
compensation breaks down, the same symptoms ensue as in the 



282 DISEASES OF THE HEART. 

venous obstruction produced in the later stages of mitral incompe- 
tence. 

Primary affections of the tricuspid valve are extremely rare. They 
occur either as a consequence of foetal endocarditis, or in the course 
of pyaemia produced by disease of the umbilicus. The occurrence of 
tricuspid regurgitation as a consequence of disease on the left side 
has already been mentioned. It leads to systolic regurgitation into 
the auricle with pulsation in the cervical veins if the regurgitation 
be considerable and the heart strong. The area of cardiac dulness is 
increased to the right of the sternum, and a systolic murmur may be 
produced which will be best heard towards the lower part of the 
sternum, often over a very limited area. Tricuspid stenosis is a not 
uncommon form of congenital heart disease, but may be acquired, 
and is then secondary to disease on the left side, usually mitral 
stenosis, of which it is a most serious complication. It produces a 
pre-systolic thrill and short, low murmur heard to the right of the 
sternum near the base of the xiphoid cartilage. Tricuspid stenosis 
produces a marked, sometimes a very extreme, degree of cyanosis. 

Disease of the aortic orifice is rare in childhood. Cases of aortic 
incompetence occur occasionally with characteristic hypertrophy of 
the heart, but as a rule the condition is associated with mitral insuf- 
ficiency. The great hypertrophy leads to bulging of the prsecordia, 
the impulse is forcible and felt over a wide area, the apex-beat is 
displaced outwards and downwards, and the cardiac dulness is in- 
creased in the same direction. A soft, long diastolic bruit, produced 
at the aortic orifice, is heard loudest at the second right interspace, 
but is conducted down towards the xiphoid. It is usually preceded 
by a short, rough systolic murmur, conducted upwards. A systolic 
murmur is often heard at the apex. It is either due to mitral in- 
sufficiency, or is conducted, a point often very difficult to decide ; in 
some instances matters are further complicated by the presence of a 
pre-systolic bruit, heard on the left side in the fourth or fifth space 
near the sternal edge ; it is attributed by Flint to a relative narrow- 
ing of the mitral orifice produced by the fact that the valves, owing 
to the hypertrophy and dilatation, are unable to swing fully back 
against the wall. The water-hammer pulse is not usually well 
developed in children, and visible pulsation of the arteries is seldom 
to be observed. While compensation is maintained there maybe no 
symptoms, when it breaks down there are attacks of dyspnoea, cough 
due to oedema of the lungs, and irregular fever from recurrent endo- 
carditis, which indeed may be the cause of the rupture of compensa- 
tion. 

Aortic stenosis, which may be brought about by an actual nar- 
rowing of the orifice, or by the obstruction offered by hardening and 
distortion of the valves, is very rare. It is produced occasionally by 



AORTIC STENOSIS. 283 

fretal endociirditis. The concentric hypertrophy which it produces 
■auses less enhirgement of the area of cardiac duhiess than tlie ec- 
centric hypertrophy of aortic regurgitation. The apex is disph\ced 
downwards and outwards, a systolic thrill may be felt at the base, 
and a bruit may be heard which may be conducted into the great 
vessels, and to the left of the sternum ; it must be distinguished from 
the ha^mic murmurs heard in that situation. These are less intense 
and harsh ; there is no thrill and no hypertrophy ; the murmur of 
aortic stenosis is best heard in the second right interspace, near the 
sternum ; the impulse is strong and sharp ; and the pulse is firm, 
slow, and of good tension. 

It is common to find evidence of lesion at more than one orifice. 
The most frequent combination is mitral disease with aortic insuffi- 
ciency ; next, but usually when compensation has given way, the 
mitral and tricuspid are diseased together. 

The prognosis of chronic valvular disease of the heart depends 
primarily on the perfection of comjx?nsation, and, owing partly to the 
steadily increasing demands made by the natural growth of the body, 
the prognosis is worse in children than in adults. The prospect is 
aggravated by the great liability to recurrent attacks of endocarditis, 
with aggravation of the lesion, and consequent early fiiilure of com- 
pensation. The prognosis is better in mitral insufficiency than in 
mitral obstruction, if the risk of embolism, which is greater in the 
latter, be left out of account. The immediate prognosis of aortic 
disease is better in children than in adults, since the vessels are not 
atheromatous. On the whole, the prognosis of mitral disease, by for 
the most common in childhood, is not good if distinct hypertrophy 
•x'cur before puberty, and is extremely bad if signs of failure of Qon\- 
]iensation appear before this age. Rest, careful dieting, and nursing 
nay procure temporary amelioration, but a fresh breakdown usually 
i.»llows a resumption of active life, and attacks of recurrent endocardi- 
tis are frequent. The risk of malignant endocarditis must also be 
taken into account. After puberty, if the patient ])e then in good 
health, and if compensation be perfect, the prospect is much brighter, 
and many such patients are able to live an active life, even to an ad- 
vanced age. 

Meddlesome treatment of chronic valvular disease of the heart is 
to l>e condemned. If there are no symptoms, no special treatment is 
called for. The jxitient should be placed under as good conditions 
as possible for the maintenance of the general health and of nutrition. 
It may Ix? well to advise against occupations or games involving 
violent exertion, such as football or racing, whether on foot or on 
cycles, since it is known that the sudden strain on the heart thus 
'^aused favors, if it may not, indeed, determine fresh endocarditis, 
he great danger which attends chronic disease. When comix?nsation 



284 DISEASES OF THE HEART. 

fails, rest, mainly in the recumbent attitude, is the first necessity, and 
the bowels should be freely moved by sulphate of magnesia, or some 
other laxative which produces copious watery evacuations. Sudden 
or extreme failure, with cyanosis and orthopnoea, may be met by 
cupping or, in extreme cases, by venesection. Digitalis is specially 
useful in dropsy, and it will often relieve this condition, if due to 
mitral incompetence, without rendering the pulse regular. For a 
child of ten HI viij of the tincture should be given three times a day, 
and increased daily until twice this quantity is taken. The urine 
should be measured, since the first indication that the dose of digitalis 
has become too high is aiforded by a sudden decrease in the quantity 
passed ; the digitalis should then be stopped for four or five days, or 
a week. At the commencement of the treatment a laxative dose of 
calomel should be given, and may be repeated after three or four 
days. In those cases in which digitalis fails to make the pulse regu- 
lar, strophanthus sometimes succeeds. It should be remembered that 
dyspnoea may be due to hydrothorax, and will be relieved on aspi- 
ration of the fluid. When other means fail to remove anasarca, the 
patient may be placed in a semi-recumbent position, with the lower 
limbs dependent. This is often followed by great relief to the breath- 
ing, owdng, apparently, to the draining of the fluid downwards. It 
will, however, then usually become necessary to remove the fluid 
from the lower limbs either by scarification or by the use of a capil- 
lary tube. In either case strict antiseptic precautions should be fol- 
lowed, and after twenty-four or thirty-six hours the patient should 
be put back to bed and the wounds induced, if possible, to heal. 
Palpitation, which is often a distressing symptom even before other 
symptoms of failure of compensation appear, is often produced by 
flatulent distension of the stomach or colon, accompanied by consti- 
pation, and is then relieved by a purgative ; indeed, if the habitual 
use of laxatives is to be excused under any circumstances, it is in this 
condition. For the insomnia of failing compensation probably the 
best hypnotic is morphia in small doses, which also will be found to 
relieve the dyspnoea in many cases, and to quiet and strengthen the 
heart. 



CHAPTER XXIV. 
DISEASES OF THE MOUTH. 

The I Mouth — Dentition — Disorders of Dentition — Stomatitis — Partial Desi^uania- 
tion — Catarrhal Stomatitis — Membranous Stomatitis — Ulcerative Stomatitis — 
Aphthous Stomatitis — Thrush — Noma. 

The hoalthv infant breathes always through the nose, and tlie 
mouth is a potential eavity only ; the tongue, when at rest, is in 
contact with the palate and with the cheeks and gums. The buccal 
secretions are scanty for the first two months of life, and the saliva 
has little action on starch ; in infants suffering from atrophy and 
diarrhcea the salivary glands may fail to secrete any amylolytic fer- 
ment even at a later age. When dentition begins the saliva becomes 

'^pious, and its diastatic action on starch marked. Owing to the in- 

rease<l secretion and imperfect adaptation of the lips much saliva 

ften dribbles away. 
In the cheek, outside the buccinator and masseter, and lying upon 
both these muscles, is a lenticular mass of fat, about Ih inches in 
diameter. Its function appears to be to prevent the falling in of 
the cheeks in the act of sucking, and the two bodies are commonly 
called the sucking-pads. In greatly emaciated infants these pads are 
not very noticeable, but above the age of six or seven months they do 
not waste with the rest of the body, and by their persistence give the 
child's face a characteristic and striking appearance. There are cer- 
tain parts of the mucous membrane of the mouth which are es])ecially 
vulnerable in infants. In most newly -born infants ('"32 per cent.) 
there may be observed one, or as many as five small, round, yellow- 
ish bodies in the mucous membrane of the jialate, generally near the 
middle line. They are termed epithelial pearls, and consist of epi- 
thelial cells packed closely together. They arc produced apparently 
by invagination during the process of closure of the palate. They 
have no pathological significance, and disappear, as a rule, during the 
second month of life at latest. If roughly handled during the jiroc- 
e^s of removing scraps of curd from the mouth witli the handker- 

hief, they may be injured and become the starting-point of uh'-ra- 

:on. 

There are two other points in the mouth of the infimt which are 
specially vulnerable. The one is at and immediately behind the ])os- 
terior edge of the hard palate, on either side ; the other a little be- 

285 



286 DISEASES OF THE MOUTH. 

hind the alveolar process. If the mouth of a youug infant be held 
wide open two pale lines will be seen running up into the soft palate 
from the posterior end of the alveolar process of each upper jaw. 
In sucking, the tongue perhaps presses back on these two pairs of 
points, but they are more probably injured during the process of 
cleaning the mouth, when the lower jaw is depressed and the mucous 
membrane put on the stretch. Symmetrical shallow ulcers may thus 
be produced over these parts, and such ulcers are known by the name 
of Bednar's aphthae. 

Dentition. — As has been well saicl,^ " Dentition is a continuous 
physiological process commencing in early foetal life and terminating 
with the appearance of the wisdom teeth at the age of from eighteen 
to twenty-two, or even twenty-five years ; but, whilst dentition may 
be said to be continuous, the eruption of the teeth is an intermittent 
process, the teeth appearing in groups and at certain intervals of 
time." 

The eruption of the milk, or temporary, teeth begins at the sixth 
or seventh month and ends about the third year. The eruption of 
the permanent teeth begins in the sixth year and ends \v\X\\ the cut- 
ting of the third molar, at some period between eighteen and twenty- 
four years as a rule. 

T\iQ first dentition is divisible into five periods : — 

( 1 ) Sixth to Eighth month T^vo lower central incisors. 

( 2 ) Ninth to Tenth month Two upper central incisors. 

Two upper lateral incisors. 

(3) Ticelfth to Fourteenth month Two upper anterior molars. 

Two lower lateral incisors. 
Two lower anterior molars. 

( 4 ) Sixteenth to Twenty-second month Four canines. 

(5) Eighteenth to Thirty-sixth month Four posterior molars. 

This is the normal sequence, but variations are common. The 
upper central incisors may appear before the lower ; the canines may 
appear earlier or later than usual, and similar irregularities may be 
observed in other teeth. Occasionally dentition begins very early, 
and children have even been born with teeth. Delayed eruption is 
far more common owing, probably, to the frequency of rickets. 

The second dentition begins at about the end of the sixth year with 
the eruption of the first molar behind the second temporary molar ; 
in the eighth year the central incisors ; in the ninth the lateral in- 
cisors appear ; and in the tenth and eleventh years the bicuspids 
replace the two temporary incisors. The permanent canines are cut 
about the twelfth year ; the second molars about the thirteenth or 
fourteenth ; and the last molars (wisdom) in early adult life (eighteen 
to twenty-four, or later). 

'By Ballantyne, "Introduction to the Diseases of Infancy." 



DENTITIOX. 287 

The eruption of the teeth is a physiological process, and may be 
attended by no local or general signs of distnrbed health, bnt, like 
other physiological processes, it may be disordered and give rise to 
symptoms of irritation, both local and geneml. AVhile the severity 
of this disorder of fnnction and the frequency with which it occurs 
have been much exaggerated in the past, the opposite error must also 
be guarded against. In the adult the cutting of the wisdom teeth 
may be attended by a feeling of general illness, indisposition to make 
any exertion, drowsiness, headache, and slight elevation of tempera- 
ture. Salivation is a frequent, if not invariable, accompaniment of 
tin? eruption of at least the earliest teeth, and some tenderness and 
itching frequently attends the distension of the gums. The child 
seeks to relieve the discomfort by chewing some hard substances, or 
the mother or nni*se scrubs the gums with her finger ; either process 
may result in producing stomatitis. In the eruptitni of the molars, 
the cusps may not come through simultaneously, and ulceration is 
very apt to take place, even in children in apparent health, under 
the flap of mucous membrane remaining over that of the crown. 
Once started this ulceration may spread by continuity along the 
groove between the teeth already cut and the gums. In infants who 
have cut only the two lower central incisors, a small ulcer not infre- 
quently forms under the tongue, apparently from the pressure of the 
teeth. It heals, as a rule, in a week or ten days, either spontaneously 
or under simple antiseptic treatment. 

Almost every disease to which infancy is liable has been set down 
at one time or another to dentition, but especially convulsions, diar- 
rhoea, and various skin eruptions. It is possible that, in a child 
already predisposed to convulsions, the irritation attending disturbed 
dentition may turn the scale. Further, the thirst often present may 
induce the child to drink indigestible quantities of milk, and thus 
gastro-intestinal disturbance may be set up, and may cause diarrhcca 
or urticaria, or both. Beyond this it is difficult, with any confidence, 
to trace a connection between teething and the disorders mentioned. 
At the time of the second dentition, a good deal of discomfort may 
be, and commonly is, produced. The teeth about to be shed l:)ecome 
loose, and in the act of mastication may easily inflict on the gum to 
which they are still attached an injury which will afford a point of 
attack to the pyogenic microbes so commonly ])r('S('nt in the mouth. 

The disorders of dentition seldom call for any active treatment. 
The routine custom of lancing the gums whenever they are found 
swollen and tender in an infant or child who presents no matter 
what nervous or other general symptoms is to be condemned 
strongly. In properly chosen cases, however, it may give instant 
relief. AVhen a molar is almost through, and especially when the 
mucous membrane over it is anaemic or shows antcmic spots, the sur- 



288 DISEASES OF THE MOUTH. 

rounding mucous membrane being of a dark crimson, and when the 
child is restless, constantly champing its jaws together, a crucial in- 
cision may be made, and will sometimes give much relief, and pro- 
cure a good night's sleep. In a few cases the thinned and anaemic 
mucous membrane over the crown is distended with fluid, and an in- 
cision into this removes the discomfort under which the child labors. 
Occasionally, Avhen the lower incisors are being cut, the gums become 
very tender, and the child is very restless, champing its jaws, and 
tearing at anything it can put in its mouth ; when with these symp- 
toms, the finger can feel the edge of the tooth through the gum, 
Avhen the mucous membrane at the summit is anaemic, and when, in 
particular, the child becomes quiet, and even holds out its mouth 
when the gum is touched, it is well to cut through the anaemic line, 
or to scratch it through with the finger-nail, previously rendered 
aseptic. The change in the child's attitude and aspect following 
this is often remarkable. 

Incision, except under the circumstances mentioned, gives little or 
no relief, and may possibly derange or interrupt the natural process. 
If at an earlier stage of eruption the gums be swollen and tender, if 
the child be restless and irritable, and if, as sometimes happens, the 
temperature ^ runs up in the forenoon without other discoverable 
cause, it is well to give a dose of castor-oil and a mixture containing 
potassium citrate (2 grains every three hours at a year old) or bro- 
mide (3 grains every two or four hours to three doses). Eubbing 
the gums gently with the finger moistened with fresh lemon juice, 
with pure glycerine, or borax glycerine (made without water) gives 
temporary relief. Vigier recommends painting the gums with a so- 
lution of cocaine (1 per cent., see Appendix). 

[Sodii SalicyL, gr. v 

Cocain. Hydrochlor., gr. viij 

Aq., Sj.] 

The temporary teeth ought to be loosened and exfoliated by a 
process of absorption of the fangs without caries ; but caries of the 
molars and incisors is extremely common, and in rickets the incisors 
and canines frequently undergo a process of disintegration at an 
early age, and are broken away down to the gums, where they show 
only as brown stumps. Sometimes the molars suffer from the same 
process, which is apparently not ordinary caries, and does not give 
rise to any obvious symptoms. 

Ordinary caries at a later age, especially when it affects the 
molars, may be a cause of ulcerative stomatitis, of adenitis, and of 
general ill-health, owing to the absorption of septic material. The 
temporary teeth are often very much neglected, and it is surprising 

1 Eustace Smith, " Disease in Children." 



STOMATITIS. 289 

how many young children, even of the wealthier classes, are per- 
mitted to evade the duty of brushing the teeth. If the child's 
health is fairly good, and if the carious teeth are not causing pain, 
they should not be extracted, as any teeth are, for the purpose of 
mastication, better than none. Children have been known to suffer 
from indigestion after extraction of stumps who had no such svmp- 
toms before. Still, such cases should be watched, havinc: re<nird 
more espt^cially to the risk of adenitis. 

Stomatitis. 

The mucous membrane of the mouth is more liable to become in- 
flamed in infancy and childhood than after the age of puberty ; the 
inflammatory pivcess has a greater tendency to involve large areas, 
and its effects are often serious, owing to the risk of secondary in- 
fections, and to the fi\ct that the tenderness may cause the child to 
refuse to take food. 

Partial Desquamation. — In children under three years of age it 
i? not uncommon to tind that the tongue presents a peculiar form of 
irregular desquamation, which from the striking resemblance to a 
map. has been called the r/eographica/ fouf/ue. Areas, which may be 
extensive, are red, and appear to be denuded of epithelium. Their 
margins are defined by curving edges of epithelium, which is a little 
paler than natural. The lesion appears to begin at several points by 
the swelling up of the epithelium, which becomes detached. The 
bare patch then formed extends in all directions, and by the coales- 
cence of various areas the irregidar patches are formed. The des- 
quamation is very superficial, the deeper layers remaining. The 
cause of this curious condition is unknown ; by some it is supposed 
to be due to the same agent as produces seborrhreic eczema, by others, 
including Unna, it is set down as a trophoneurosis. It is important 
to recognize that it is not, as sup^XJsed by Parrot, a sign of congeni- 
tal syphilis. Children in whom geographical tongue is seen are 
usually suffering from some form of chronic gastro-intestinal dis- 
turbance, and the desquamation of the tongue ceases when the con- 
ditinii of the digestive organs is improved. 

Catarrhal Stomatitis. — Catarrh of the mucous membrane of the 
mouth is the almost invariable accompaniment of certain acute sjX'ci- 
fic fevers (e. 7., scarlet fever, measles) and «>f coryza. It is fre- 
quently associated also with dentition, appearing shortly before the 
I'uption of each tooth or set of teeth ; it may be caused also by 
(leaning the mouth with handkerchiefs, or by the use of dirty or old 
and cracked bottle teats. Catarriial inflammation, limited in extent, 
especially over the hard jialate, a|)pears often to be determined by 
the retention of decompf>sing scraps of curd, especially in fccl)le in- 
fants. After the deciduous teeth have been cut they may early be- 
19 



290 DISEASES OF THE MOUTH. 

come carious and determine stomatitis, acting either mechanically, 
by the irritation of sharp edges, or as a source of infection, owing to 
the decomposition taking place in the carious cavities. 

The mouth feels hot and sticky. If the child is at the breast the 
mother may notice that the lips are burning, and that the child stops 
sucking frequently to cry. The mucous membrane will be seen to 
be swollen and oedematous. Redder patches may be seen here and 
there, and when this aspect is well marked the term erythematous 
stomatitis is sometimes applied. Or the mucous membrane may be 
generally somcAvhat pale from the oedema, and, if teeth be present, 
marked by depressions corresponding to them. There is some ful- 
ness under the jaw, due to adenitis, and some oedema about the 
glands. The breath is slightly offensive, and the temperature may 
be raised a degree or two. 

Acute attacks, associated with the specific fevers or with dentition, 
commonly subside at once with the disease or as the tooth comes 
through ; but when the cause persists, the condition may become 
subacute or chronic, or pass on to ulceration. 

In the treatment of catarrhal stomatitis it is well to bear in mind 
that the catarrh may be kept up, if not, indeed, caused by the food 
and drink being given too hot. To clean out the mouth of an in- 
fant with a handkerchief over the finger is meddlesome. In feeble 
infants or young children who owing to pharyngeal or nasal obstruc- 
tion breathe habitually through the nose, it may, however, be neces- 
sary to clean the mouth at night or after each meal. For this 
purpose a large soft camel-hair brush dipped in glycerine (or 
borax-glycerine) and water, equal parts, is the best means to employ 
until the child can be taught to wash out its mouth with boiled 
water which has become lukewarm, or a weak (1 per cent.) solution 
of borax. The mouth should always be cared for during specific 
fevers, especially measles and scarlatina, by the use of mouth washes 
(see Appendix) in children old enough to use them, or by gently 
painting the mucous membrane with borax-glycerine (two parts) and 
water (one part). 

[(The following local applications for the mouth may be used :) 

(a) Pot. Permang., gr. ij-iv (b) Cupr. Sulph., gr. xxiv 

Aq., 5J M-, SJ 

(c) Resorcin., gr. iv-viij 

Aq., 5J 

(The following may be used as mouth-washes :) 

(a) Thymol., gr. vj Thymol., gr. iij 

Boracis, 5^8 Sod. Benzoat, ^iv 

Spir. Rect., %i^ Tr. Encalypt., 3y 

Aq. Dist., ad Oj Aq. Dist, ad Oj 

Borac Acid Cream. Appendix.] 



MEMBRAXOVS STOMATITIS. 291 

For marked catarrhal stomatitis no remedy is better than potas- 
sium chlorate, either in solution (1 to 2 per cent.), or in the form of 
lozenges or tabloids. In infants glycerine of boric acid or potas- 
sium chlorate may be applied with a brush. AVhatever remedy is 
used, it must be used very frequently, and if lozenges or tabloids are 
preferred they should be broken into four or live pieces to be sucked 
separately. 

Membranous Stomatitis {aphfhouf< s.). — Catarrhal stomatitis when 
limited in extent, but acute in degree, may produce so much heaping 
up of epithelium and o?dematous swelling of the superficial parts 
oxTr limited areas as to give rise to patches resembling false mem- 
brane. These patches, which arc of a yellowish, or greenish, color, 
and vary in size from a pin's head to a pea, may be seen on any part 
of the mucous membrane of the mouth or tongue ; the plaques are 
surrounded by a zone of erythema which may be no more than a 
narrow band, or may extend over wide areas. 

The symptoms are heat and soreness of the mouth, salivation, foetor 
of the breath, and thirst, fever, restlessness, loss of appetite, swell- 
ing of the glands below the jaw, and oedema of the connective tis- 
sue about them. The condition is probably due to the local develop- 
ment of pyogenic organisms (the organism most commonly found is 
glaphylococcus pyogenes cntreus). It tends, as a rule, to spontaneous 
recovery, a process which may be hastened by the use of antiseptic 
mouth washes or creams. In weakly children, or in the subjects of 
gastro-enteritis, measles, scarlet fever, whooping-cough, pneumonia, 
and other acute febrile diseases, the inflammatory process may extend 
more deeply, and the patches then easily bleed. Eventually the 
plaques, which when hiemorrhage has occurred are much thickened 
by blood-clot, become loosened by ulceration. Their final detach- 
ment by this process is commonly attended by much pain and some 
hfemorrhage. 

The treatment of the early stage of this condition consists in the 
use of general mouth washes (boric acid, potassium chlorate or per- 
manganate), and the local application of a solution of perchloride of 
mercury (1 to 2 in 1,000), or of sodium salicylate and cocaine (see 
Appendix). In the later stages creams and other greasy applica- 
tions, or glycerine of borax, or carbolic acid, or resorcin may be used 
with a'lvantai:<'. '''spf<"ially if crusts form. 

Ulcerative Stomatitis. — The main etiological fiictor in the pro- 
duction of ulcerative stomatitis is traumatism, but if the mucous 
membrane is already in a catarrhal condition, ulceration may ensue 
upon injuries which in a healthy mouth would have no such effect. 
A carious, or sharp-edged tooth which has jx-rhaps long existed, may 
then determine ulceration. In children who have cut only the two 
central incisors in the upper (or lower) jaw, an ulcer may thus be 



1 



292 DISEASES OF THE MOUTH. 



produced in the mucous membrane at the point where the teeth im- 
pinge when the jaws are closed. Ulceration may occur at any part of 
the buccal or lingual mucous membrane^ but there are certain sites 
where it is most frequently produced, or, at least, most frequently 
calls for treatment — at the edge of the tongue, or on the cheeks op- 
posite the crowns of the teeth, in the groove where the gums over- 
lap the teeth, and in the sulcus between the upper, but especially the 
lower lip, and the jaw, where the mucous membrane is reflected from 
the one to the other. Or the ulceration may begin in numerous 
scattered points sometimes grouped like herpes (herpetic stomatitis) ; 
tliis form, in fact, occurs frequently, but not always, in association 
with herpes labialis, or impetigo about the mouth. In the earliest 
stage a group of scattered spots are seen on the cheek or lip, or the 
side of the tongue ; they are whitish, and slightly raised, consisting 
apparently of necrosed and swollen epithelium ; this is quickly de- 
tached, leaving a shallow ulcer with sharp, or in some cases, under- 
mined edges. These ulcers may quickly heal, or they may ex- 
tend, and by confluence form ulcers of various forms, but commonly 
elongated. 

In some cases ulceration of the gums extends to the bone and 
causes extensive necrosis ; in association with acute infectious dis- 
eases, especially scarlet fever and typhoid fever, extensive sloughs, 
which may have a gangrenous character, occasionally form and in- 
volve parts of the jaw, the tonsils (leading perhaps to ulceration into 
the internal jugular vein), or soft palate, leaving after recovery a 
perforation. 

The treatment of ulcerative must be governed by the same general 
considerations as that of catarrhal stomatitis. In the early stage 
potassium chlorate is a valuable remedy, but is less effectual later. 
The main difficulty in treating ulceration of the mouth, when it has 
become thoroughly established, is to ensure that the antiseptic used 
reaches all parts of the ulcer, as is well illustrated by the extreme 
obstinacy of ulceration in the groove between the gums and teeth. 
Moreover the copious salivation which often accompanies the stomatitis 
tends to wash away any local application. Sulphur ointment (ung. 
sulph. (B. P.), adeps lanse, vaselinse aa) meets the indications, and is 
an effectual but disagreeable remedy ; a lanoline cream may be used 
as a basis for various antiseptics, potassium chlorate, borax, resorcin, 
etc. (see Appendix), and has the advantage that the lanoline appears 
to penetrate well, and remain for some time attached to the ulcerated 
surface. Painting the ulcer with a solution of mercury perchloride 
(1 to 2 per 1,000) in the early stage, or with a solution of sulphate 
of copper (gr. xx to 3j) or nitrate of silver (gr. v-x to Sj), or touch- 
ing the small accessible ulcers with lunar caustic two or three times 
a week, helps to bring about a healthier condition. A solution of 






APHTHOUS STOMATITIS. 29a 

potassium permanganate (1 per eent.) is well s[X>ken of, and a solu- 
tion of sodium salicylate and cocaine is also recommended (see Ap- 
pendix). In any case it should be Ixirne in mind that ulceration of 
any part of the mucous membrane of the mouth which is much used, 
as, for instance, in the sulcus between the lower lip and the jaw, may 
cause great pain, and so render the child restless, irritable, and 
averse to food. Under such circumstances small doses of opium, 
which have the further etfect of diminishing the excessive flow of 
-aliva, may be of great service. 

Aphthous stomatitis is an infectious disorder derived from cattle 
-uttering from aj^hthous fever (foot and mouth disease). In children 
infection takes place throuofh the iuirestion of the milk of an infected 
COW. as a rule, but it may also be transferred from one child to 
another residing in the same house and using the same drinking 
vessels. 

The earliest symptoms are fever accompanied by salivation, indis- 
|>osition to take the bottle, and often by diarrhoea. Red spots then 
apj>ear on the tip or sides of the tongue, or on the lips or palate. 
At the centre of the red s}X)ts vesicles form, and persist, surrounded 
by a red zone, for two or three days. The vesicle then bursts, 
leaving a sharp-edged shallow ulcer covered with a puriform false 
membrane. As a rule, only some eight or ten vesicles form and the 
ulcers do not coalesce. In such cases the disease is mild and tends 
spontane<3usly to recovery, though a phlyctenular eruption, probably 
due to infection from the mouth, may appear on the cheek, chin, 
arms, or hands. AVhile the ulcers persist, the mouth is sore and 
painful, the fever continues, and the sub-maxillary glands may be- 
come enlarged. When the vesicles are numerous the resulting 
ulcers may coalesce and involve not only the palate, but the tongue, 
lips, and even the pharynx. All the symptoms are then much 
aggravated and tlie child may pass into a typhoid condition. After 
recovery from a mild attack, a second, and even a third may occur 
if the use of the infected milk be i)ersisted in. 

The prognosis is generally good. 

The diagnosis can only be made with certainty in those cases in 
which the vesicles are observed. 

Much difference of ojnnion exists as to the frequency with which 
this disease f»ccurs in the human species ; infants imder two years of 
ai,re are certainly more liable to it than older children. 

When there is reason to suspect that stomatitis is of this nature, it 
is, of course, desirable to change the source of milk supj)ly, or, if this 
be not {possible, to l>oil the milk. The mouths of other children who 
have been taking the milk should be carefully examined, and simple 
antiseptic mouth washes prescribed. In the treatment of the 
disease a strong s<^>lution of sodium sjdicylate (20 jxt cent.) has been 



294 DISEASES OF THE 310 UTH. 

strongly recommended as a mouth wash ; when there is much pain a 
sohition of cocaine hydrochlorate (2 per cent, for infants, 5 per cent, 
or 10 per cent, for older children) should be applied to the parts Avith 
a brush. In order to prevent intestinal complications it is advisable 
to give salol (gr. ij to iij four times a day to an infant ; gr. v to a 
child of two to three years), or naphthaline, or salicylate of naphthol. 

Thrush is a term often loosely applied to any soreness of the mouth ; 
it is here limited to the special affection of the mouth produced by the 
saccharomi/ces albicans. 

This form of stomatitis, which is seen in its characteristic form in 
marasmic infants, especially in those suffering from gastro-intestinal 
derangements, presents three stages. In the first, or erythematous 
stage, the mucous membrane is of a dusky red, the tongue is dry and 
glazed, its papillae enlarged, and the secretions in the mouth are acid. 
The infant sucks with some difficulty, but does not appear to be in 
pain, and there is no obvious glandular enlargement. After a day or 
two the creamy membranous growth characteristic of the second stage 
begins. Small points and patches, at first of the most brilliant opaque 
white, form on the dorsum, tip, and sides of the tongue, often also on 
the cheeks and lips. Spreading rapidly, these patches cover the parts 
affected with a white layer, which on the tongue especially is particu- 
larly uniform, as though a finely granular w^hite paint had been spread 
over it with a spatula. On the cheeks and hard palate it is, if present, 
nsually less uniform, and has rounded scalloped edges. The creamy 
layer can be removed, commonly with great ease, and the mucous 
membrane is then seen to be reddened, but not ulcerated. The 
membrane forms again quickly after removal. In the third stage 
the membrane loses its brilliant Avhite color and uniformity ; it turns 
yellow or gray, and becomes detached in places, or if the patient is 
sinking, it assumes a dark gray or brown color and dries into cakes. 

Though usually limited to the mouth the membranes may extend 
beyond the fauces to the pharynx, oesophagus, stomach, and even to 
the small and large intestine ; the infection may become established 
in the vagina, but not, it is said, in the rectum. In robust infants 
the infection does not spread so widely or rapidly, and is commonly 
limited to a few scattered patches on the tongue or hard palate. In 
them it produces few or no symptoms beyond some slight indisposi- 
tion to suck freely. In the severer forms the child refuses to suck, 
and the movements of the tongue are slow and slight. Even in 
them, however, thrush is rather of importance clinically as an indi- 
cation of an extreme state of prostration than in itself a cause of that 
condition. 

The pathology of the condition has nevertheless given rise to much 
speculation. If a particle of the membrane be detached, cleansed 
with potash, and examined under the microscope it will be seen to 



yOMA. 295 

Ci>nsist of epithelial cells, food debris, and of matted filaments with 
some rounded bixlies resembling spores ; leptotlirix filaments and 
other micro-organisms may also be seen. The larger filaments belong 
• the specific organism, but it appeai-s that they are not a true my- 
celium. Cultivated on solid media it forms white colonies, which 
are found to consist of nnnukxl cells enclosed in a refracting capsule ; 
these cells multiply by gemmation. In fiuid media the cells become 
elongateil, giving origin to a false mycelium. True spores form only 
in sugary media. Much imjx>rtance has been attached to the acidity 
of the secretions of the mouth observed in thrush, but it appears that 
the saccharomyces will grow as well in neutral or alkaline as in acid 
nuMiia. It will not, however, grow in saliva, which agrees with the 
clinical observation that thrush occurs most often during the first two 
Dionths of life, when the secretion of saliva is scanty or absent, or 
during febrile or wasting diseases which tend to suppress the secre- 
tion. It is probable that the sequence of events is that particles of 
curdled milk retained in the mouth during sleep and in the weakness 
of fever or mamsmus undergo acid fermentation, determining an 
erythematous stomatitis, which then becomes the seat of the specific 
infection with saccharomyces. The mycelial-like elements of the 
saccharomyces grow between the epithelial cells, which undergo 
necrosis, and may even force their way into the submucous tissue or 
between the muscle fibres ; in rare instances they find entrance into 
the lymphatics, and have been found in internal organs (kidneys, 
spleen, brain). The origin of the infection cannot always be traced, 
but the disorder has occurred in epidemics in lying-in and foundling 
institutions, and under such circumstances is probably conveyed from 
one infant to another by the india-rubber teats of the feeding bottles, 
or by other utensils used in common. 

Thrush is not in itself the cause of much discomfort or danger ; it 
may Ix? frratcfl by glycerine of borax or glycerine of mercury per- 
chloride applied with a stick tipped with cotton-wool, or by solutions 
of ix)tassium permanganate (1-per-cent. ) or borax (2- to 4-per-cent.) 
applied in spray. At the same time it is usually desirable to give 
salol or other intestinal antiseptics, or to treat any gastro-intestinal 
disorder which may be present. If the white layer reaches far back 
and invades the pharynx, Baginsky recommends the administration 
every two hours of a drachm of a srdution of resorcin (gr. ij-iv 
in ?,'} ). 

Noma is a peculiar form of spreading phlegmonous inflammation 
leading rapidly to gangrene ; it attacks the cheek (cancrum oris) and 
vulva. 

It is now a rare disease. Its victims are children between the 
:[(■< of two and seven or eight years who have been brought into a 

' lifM-tic condition by a recent attack of measles, scarlet fever, or 



296 DISEASES OF THE MOUTH. 

some other acute infectious fever, by malaria, or more rarely by 
chronic gastro-enteritis or an insufficient diet. 

In cancrum oris the earliest symptom is a thickening of the cheek 
between the skin and mucous membrane. Whether this is always 
preceded by ulceration of the buccal surface is doubtful, but as a rule 
at least ulceration is present when the case is first seen. The indu- 
ration spreads rapidly, and accompanying oedema renders the whole 
cheek brawny ; the skin becomes involved in the inflammatory proc- 
ess, and is generally red, with a purplish tinge. On the buccal 
surface gangrene may occur early and spread rapidly both towards 
the surface, causing sloughing of the skin, and internally to the gums, 
the periosteum, and the bones. The deformities resulting may be 
extensive. 

The local process does not produce much pain. It is accompanied 
by general symptoms of a low adynamic type. There is not much 
fever and the temperature may not be at all elevated. Septic diar- 
rhoea, and septic broncho-pneumonia are apt to occur, rendering the 
prognosis exceedingly grave. Pulmonary gangrene and gangrene of 
the extremities have also been observed. 

Noma of the vulva may occur as a complication of cancrum oris, 
or independently. It runs a rapid course, and may quickly deter- 
mine extensive gangrene. 

This form of spreading gangrene is due to a short bacillus which 
in cultivation forms, by juxtaposition, long threads. Occasionally 
several cases have occurred in succession in foundling institutions, but 
as a rule the mode of infection cannot be traced. 

The treatment must consist in scraping the surface, followed by 
the free application of the acid solution of nitrate of mercury or of 
nitric acid and the subsequent use of antiseptic applications. The 
operation must be performed under an anaesthetic. The patient must 
be given a diet which is nutritious but light (predigested). Alcohol 
is often required in full doses. 



CHAPTER XXV. 
DISEASES OF THE UPPER RESPIRATORY PASSAGES. 

Rhinitis — Acute Laryngitis — Chronic Laryngeal Catarrh — Papilloma of the Larynx 
— Acute Pharyngitis — Acute Tonsillitis — Otitis Media — Chronic Pharyngitis — 
Adenoid Vegetations — Chronic Tonsillitis — Deformities of the Chest produced 
by Xaso-Pharyngeal Obstructions — Retro-Pharyngeal Abscess — Respiratory 
Spasm. 

Rhinitis. — Infimts sueeze a good deal during the first few days of 
life. There are no distinct signs of catarrh, and the sneezing is due 
to the mechanical irritation of dust in the air, but for the whole of 
the first year they are very liable to acute rhinitis, which is often 
'omplicated by catarrh of the naso-pharynx, pharynx, and mouth, 
and sometimes by bronchitis. After exposure to cold the infant 
l>egins to sneeze, to breathe through the mouth, owing to obstruction 
of the nasal passages caused by the hyper^emia which is the first 
^tage of catarrh, and to have some difficulty in suckling. Shortly a 
thin mucous secretion begins to run from the nose, and excoriation 
of the upper lip is apt to ensue. There is some elevation of tem- 
I)erature, and the infant is restless and does not sleep well. The 
secretion becomes muco-purulent, and owing to its stickiness and to 
its drying in the nose and at the nostrils obstruction to respiration 
continues. The infant takes the nipple into its mouth, but is quickly 
compelled to relinquish it to take breath. When this has occurred 
twice or thrice it becomes restless, cries, and may refuse altogether 
to suck. 

Gastric catarrh is a frequent complication, and rapid wasting may 
ensue owing to an insufficient quantity of milk being taken and im- 
perfectly digested. Attacks of inspiratory dysjinoea may occur, 
which in rare cases have been traced to falling ])ack of the tongue in 
inspiration. Ivolapses and rejx^ated attacks arc common. In young 
infants the diagnosis must be made from syphilitic rhinitis (7. r.) and 
from diphtheria. Much swelling of the nose, and the early appear- 
ance of a muco-purulent secretion, esj)ecially if it have an offi'usive 
-mell and Ije associated with depression and somnolence, should ex- 
cite suspiciftn of di|)htheria, and the fauces and pharynx should be 
exaraine<l thoroughly. [The question can be .settled only by Ixic- 
teriological examination, which should always be made in suspicious 
cases. See chapter on Diphtheria.] At a somewhat later age the 

297 



298 DISEASES OF THE UPPER RESPIRATORY PASSAGES 

probability that the rhinitis marks the commencement of measles or 
whooping-cough must be borne in mind. 

The treatment should consist of the injection, very gently, of mild 
antiseptic lotions (boric acid) and the application of soft ointment 
(f. (7., boric acid) to the anterior part of the nasal cavity with a 
camel-hair brush ; or the ointment may be applied on plugs of cotton- 
wool, large enough to distend the nostrils slightly, which are left in 
place for half an hour. If the secretion is muco-purulent and irri- 
tating, a mild white precipitate ointment is to be preferred. Should 
the infant be unable to snck it must be fed with the spoon. 

Acute laryngitis varies very much in severity. In severer cases 
there is in addition to catarrhal inflammation much sub-mucous 
oedema, and it may be inflammation, which may extend to the carti- 
lages. In this severe form it is not a common afl'ection except as a 
complication of diphtheria, sometimes of scarlet fever or measles, 
more rarely still of typhoid fever, or small-pox. The symptoms 
are identical with those produced by laryngeal diphtheria, and it is 
often impossible to be certain that the laryngitis is not diphtherial. 
The reader is, therefore, referred to the article on diphtheria. 

In the milder form to which the term laryngeal catarrh is often 
applied, there is a catarrh of the mucous membrane which is red, 
swollen, and at first dry, but afterwards covered with a watery mucous 
secretion. The catarrh may begin in the subglottic part of the 
larynx, and may be attended by some sub-mucous oedema. As a 
rule it is secondary to acute catarrh of the nose and pharynx (coryza) 
or of the bronchi, and in some is apparently produced by direct ex- 
tension of the inflammatory process. One attack predisposes to 
another, and a slight exposure to cold, or to dusty air, may deter- 
mine an attack in children who have once suffered. This liability 
is one of the most frequent sequelae of measles. 

The symptoms are in the main the same as those of sub-acute 
laryngitis in the adult, with one characteristic addition — ^^ croup '^ — 
which is due to a reflex spasm of the glottis-closers. An infant, or 
young child, w^ho has, perhaps, begun to suffer from an attack of coryza 
during the day, awakes suddenly struggling for breath ; after, per- 
haps, a few husky coughs the chest becomes fixed in expiration, the 
face congested, the eyes suffused, and the attack terminates by a 
long, noisy, high-pitched inspiration. The child then begins to 
cry and cough, and both cry and cough may be a little husky, or 
quite natural. Such an attack causes great alarm in a household,^ 
but by the time the child can be seen it is probably sleeping peace- 
fully. It is, however, very likely to awake again once or twice in 
the same night with similar attacks. The next day it appears quite 

^See Henoch's graphic description { Vorlesungen, S. 332; New Syd. Soc. Trans., 
vol. i., p. 357). 



CHROyiC LAEYXGEAL CATARRH. 299 

well, or it niav present the ordinary symptoms of slight eoryza, or 
the voiee may be a little hoarse, antl the eongli " eronjn- " ' — that is 
to say, lond and elangino-. Attaeks of eroup may recur during the 
following night, but this is not the rule, as they seem to be associated 
usually with the dry, early stage of laryngeal catarrh and to cease 
when secretion becomes established. 

Treatment during or innnediately after an attack of croup should 
U^ directed to relieving the laryngeal congestion by hot compresses, 
or poultices, or a mustard leaf to the front of the neck, and the 
mitigation of the dryness of the mucous membrane by keeping the 
air of the room moist and warm (65° F.). In children old enough 
to use it an inhalation of steam with tincture of benzoin gives relief. 
The routine use of emetics is not to be recommended, but after the 
croup has passed away ipecacuanha in small doses repeated every 
hour or every two hours is of use in ])romoting secretion. It is not 
desirable to add opiates in the early stage, but later, if the cough be 
frequent, the compound tincture of camphor or a linctus containing 
a small dose of morphine, or codeine (gr. t>^^ to gr. J) may be given 
in the evening. When a child has once had an attack of croup the 
prophylactic treatment is of much importance. It should be warmly 
clad, taken out in the open air as much as possible, but not in very 
damp weather ; if old enough gymnastic exercises are useful, and in 
summer a bracing climate, and an out-of-door life. 

Chronic Laryngeal Catarrh occurs in children as a sequel to 
the acute affection, and occasionally in association with chronic 
pharyngitis and adenoid vegetations. Inherited syphilis ap])ears to 
be the cause in some cases in young children, and in older children 
chronic laryngitis is sometimes associated with sub-acute relapsing 
rheumatism. The mucous membrane is thickened and there is 
hoarseness, and chronic cough. Occasionally the thickening is pro- 
gressive and the obstruction to respiration may necessitate tracheotomy. 

Symptoms resembling those of chronic laryngitis are occasionally 
found to be due to new growths in the larynx, of which the com- 
monest is papilloma. In such cases there are usually many grayish 
white warty growths on and about the cords. In other cases the 
growths are larger, more vascular, and even pedunculated. When 
this is the case sudden fatal asphyxia may l)e j)roduc{'d by impac- 
tion of a grf>wth between the vocal cords. The earliest age at which 
papillomata have been observed is fourteen months." Medicinal 
tr^tment is ageless. Partial extirpation is apt to be followed by 
-. (Urrence, and thorough extirpation necessitates thyrotomy, which 

'"Croup" is the loud inspiration fhie to plottic spasm; "croupy cough" the 
short loud clanging or ringing cfiugh of slight laryngeal catarrh. 

'In a child who had been hoarse since six weeks old (I'orneinann, Jalir. f. Kin- 
hlldf, IW. XXXV., S. .33.3). 



300 DISEASES OF THE UPPER RESPIRATORY PASSAGES 

may leave permanent hoarseness. If sources of irritation — the pas- 
sage of air in breathing, but especially the violent movements of 
coughing — are removed, the growths tend to undergo spontaneous 
atrophy. The best treatment ^ appears to be to perform tracheotomy, 
and to let the child wear a soft rubber tracheotomy tube until all trace 
of obstruction has ceased and the voice has regained its natural 
quality. It may be necessary to continue the use of the tube for 
several years.^ 

Acute inflammatory affections of the pharynx and of the adenoid 
tissue in relation with it, are of great importance in childhood owing 
to the frequency with which they occur, and the difficulties in diag- 
nosis which they often present. As a rule the mucous membrane 
and the adenoid tissue (tonsils and pharyngeal tonsils) are involved 
simultaneously, but the one or other tissue may be the more severely 
affected. 

Although acute pharyngitis is usually determined by infection or 
exposure to cold, or by one of the specific diseases — scarlet fever, 
measles, small-pox, chicken-pox, erysipelas, acquired syphilis — fam- 
ily predisposition, insanitary dwellings, and chronic catarrh must be 
reckoned as predisposing causes. 

The symptoms of acute pharyngitis are commonly less severe than 
in adults ; there is some elevation of temperature, which may reach 
101°-102°r. for a few hours, but soon falls. It is accompanied by 
some increase in the pulse and respiration ; the breathing is a little 
noisy ; there is some cough, and the child hawks up a good deal of 
glairy mucus. Pain on swallowing is less than in adults, but com- 
plaint may be made of pain about the angle of the jaw, and the 
glands there will be found enlarged and tender. On inspecting the 
throat in the early stage red patches are seen, a little later a uniform 
redness and swelling of the mucous membrane, which is covered by 
a thin, frothy mucus. The mucous glands are usually swollen, and 
rounded prominences about the size of a pin's head form, thickly set, 
which may break down, causing small superficial erosions ; the pil- 
lars of the fauces may be of a purplish color and oedematous. Some 
enlargement of the tonsils is frequent, but in a first attack it is 
usually slight. In seven cases a thin whitish false membrane may 
form, generally on the tonsils or the pillars of the fauces. 

In other cases, usually attended by extensive oedematous inflam- 
matory swelling of the mucous membrane of the fauces and pharynx, 
the tonsils are more acutely inflamed. They are large, bright red, 
soft and tender. Some cases, to which the term, follicular tonsillitis is 
applied, show groups of yellowish points due to superficial suppura- 
tion beneath the epithelium. These may break dow^n, leaving shallow 
ulcers. 

1 Hunter Mackenzie, Brit. Med. Journ., 1896, vol. ii., p. 609. 
2RaiIton, Ibid., 1898, vol. i., p. 488. 



CHBOXIC LARYNGEAL CATAIiEH. 301 

In other cases agjiin, which are undoubtedly infectious, the inflam- 
mation of the tonsil^ is more deeply seated ; they are swollen, firm, 
and the mouths of the laeunie are plugged with a cheesy purulent 
secretion [aur/ina hciinaris). There may be a thin white false mem- 
brane on the tonsils, and, as the cases occur with special frequency 
during times of diphtheria prevalence, the diagnosis is often difticult. 
The disorder lasts two or three days, and ends often by crisis. In 
these forms of acute tonsillitis both organs are usually atfected and 
commonly to about the same degree. 

Finally, the inflammation of the substance of the tonsils may be 
sutticiently acute and extensive to produce snj)pHrafio)i. Tlie swell- 
ing of the tonsils is very great, so that they meet in the middle line, 
or if one be aflected more than the other, as is often the case, it 
bulges across the middle line, until it is in contact with its fellow on 
the other side. There is a great deal of mucous secretion, which 
often dribbles from the mouth, much pain on swallowing, and en- 
largement of the glands at the angle of the jaw (often mistaken for 
the tonsils). This acute phlegmonous tonsillifis may end in suppura- 
tion (a) in the tonsil, (6) more often in the connective tissue about it 
(l^eritonsillar abscess), or (r) in the lymphatic glands, in which case 
the abscess presents externally behind the jaw. 

Inflammation of the tonsils and pharynx may be so intense that 
f/nnf/rene ensues, causing great destruction of tissue, which has led, in 
some cases, to opening up of the carotid, and profuse ha?morriiage. 
This severe form has been observed chiefly as a complication of scarlet 
fever. When the tonsils are the part mainly aifected, the symptoms 
are more severe and acute, and the fever, which is often preceded by 
shivering, a rigor, or even by convulsions, is high, 10.*5°-104° F. 
Severe tonsillitis is rare in iuflmts, and comparatively imcommon in 
young children ; at about six or seven years of age it begins to be 
more frequent, and it is very common about the age of puberty. 

Since acute pharyngitis and tonsillitis may be the earliest mani- 
festations of several acute specific diseases the diagnosis is often ex- 
ceedingly difficult. In([uiry should be made as to the prol)al)ility of 
recent exposure to infection, by scarlet fever and diphtheria in par- 
ticular, and as to the acute specific diseases from wliieh the patient 
has suffered previously. Tonsillitis and acute pharyngitis also fre- 
quently prevail epidemically in schools. The only safe rule is to re- 
gard every sore throat as possibly infectious, and to isolate the patient 
from other children. Yery sudden onset, with vomiting or convul- 
sions and a high temperature, is in favor of scarlet fever; ** straw- 
berry- '' tongue will exeite suspicion, and the rash will deelare itself 
within twenty-four hours. If due to measles the pharyngitis will 
prolmbly be accompanied by coryza, bronchitis, and congestion of 
the face. Acute pharyngitis, accompanied by paroxysms of cough, 



302 DISEASES OF THE UPPER RESPIRATORY PASSAGES. 

especially if these end in vomiting, is, in children who have not suf- 
fered from the disease, due probably to whooping-cough. At an 
early stage it may be quite impossible to exclude diphtheria ; it must 
be remembered that a sore throat, especially in children who have 
already suifered from diphtheria, may be diphtherial though no 
membrane be present throughout the case. Bacteriological exami- 
nation will afford confirmatory evidence, but too much reliance must 
not be placed on a negative result. A thin white membrane, espe- 
cially if semi-transparent and associated with tonsillitis, does not 
justify the immediate diagnosis of diphtheria. The child should be 
isolated and watched ; in such cases the membrane often clears away 
very rapidly and the bacteriological examination is negative. 

Otitis is a frequent and most serious comphcation of pharyngitis. 
It is particularly apt to occur as a complication of the acute specific 
diseases, especially of scarlet fever and measles, but it is not infre- 
quent as a complication of simple pharyngitis and of acute tonsillitis. 
It is due to infection of the middle ear by extension from the air 
passages, but its occurrence is favored by the obstruction of the 
Eustachian tube produced by swelling of the pharyngeal mucous 
membrane. The inflammation is at first catarrhal and is soon attended 
by suppuration. Subsequently the inflammatory process may extend 
to the mastoid cells, to the cranial bones, the meninges, and the brain 
(vide ^' Abscess of the Brain ''). The microbes found are the diplo- 
coccus pneumonke of Fraenkel, the bacilhts pneumonice of Friedlander, 
the streptococcus pyogenes, and the staphylococci {albus and aureus). 
Of these Fraenkel' s diplococcus, and the streptococcus, which is the 
microbe most often met with in the otitis of scarlet fever,^ are those 
found most frequently. 

The symptoms of otitis media are acute pain in the ear and the side 
of the head, tenderness over the ear and behind the angle of the jaw, 
with usually some redness and swelling of the external canal ; if the 
drum can be seen it will be found red or bulged forward. If the 
child be already suffering from an acute fever the onset of the otitis 
is very apt to be overlooked. It should be suspected if the child 
show that it is in constant pain by whining continuously, with an 
occasional sharp cry. The diagnosis will be confirmed if the child 
pick or rub at its ear, and if the intelligence be dulled, or if the tem- 
perature remain high, after, in the ordinary course of the disease, it 
should fall, and especially if it assume the suppurative type. An 
infant suifering from acute otitis media cries unceasingly, and utters 
occasionally shrill, quavering screams. It bores its head into the 
pillow or holds it motionless on the nurse's shoulder, and very often 
tears at the external ear. It is feverish, restless, and refuses food. 
In other cases the symptoms closely resemble those of posterior basal 
'Blaxall, BriL Med. Journ., 1894, vol. ii., p. 116. 



OTITIS. 303 

meningitis, retraction of the head being marked, vomiting and con- 
vulsions not infrequent, while symptoms directing attentit>n to the 
ear are absent. Sooner or later in most eases the drum is perforated, 
a thick purulent discharge escapes, and all the symptoms are at once 
alleviated. The occurrence of mastoiditis will be indicated by ten- 
derness and indammatory ivdema over the mastoid process. It is, 
however, more often a complication of chronic than of acute otitis 
media. 

In the treatment of acute pharyngeal catarrh, fomentations or a 
cold compress to the neck, and warm washes (boric acid) for the 
mouth and as gargles, give relief. The fauces and pharynx should 
be brushed lightly three or four times a day with glycerine of tannin 
or borax, or strong solution of perchloride of iron and glycerine 
(equal parts) or chloride of zinc. Small doses of potassium chlorate 
in decoction of cinchona, with perhaps some ipecacuanha are useful, 
but antipyretics are seldom called for. In follicular tonsillitis the 
internal administration of sodium salicylate relieves the pain and 
apparently hastens resolution. Quinine is also recommended. 
Guaiacum in small doses, if given at the onset of an attack of tonsil- 
litis, will sometimes cut it short. A lozenge containing gr. ij-iij, 
should be sucked every two or three hours. As local applications, 
the glycerine of tannin and of perchloride of iron are of value. 
Sucking small pieces of ice relieves the pain, and the local applica- 
tion of a solution of cocaine (5 per cent.) diminishes dysphagia. A 
brisk purge at the onset of symptoms is to be recommended. 

In acute pharyngeal catarrh, whether primary or secondary, the 
liability to the occurrence of acute otitis media must always be kept 
in mind ; much may be done for its i)revention by the use of anti- 
septic mouth washes, and by the application of warm solutions of 
boric acid by a coarse spray or syringe through the nose, followed by 
the applicatif>n of an antiseptic ointment with a ci\mel-hair brush. 
Pain in the ear may be relieved by hot fomentations, or a leech to 
the mastoid, and by the instillation of a small quantity of a watery 
Sf>lution of cocaine and atropine (of each 2 per cent.). If these 
measures fail to give relief in a short time the tympanic membrane 
should l>e punctured by a vertical incision in the posterior section. 
Owing to the smallness of the parts, and the very f>blique j)osition 
of the tympanic membrane in relation to the external auditory canal 
in infants, it is often difficult to obtain a satisfactory view of the 
drum, but if the symptoms |)oint to ear disease, and in cases in which 
they resemble those of posterior basal meningitis, it is advisable at 
once to perform paracentesis f>f the tympanum. The puncture heals 
ea.sily, so that if the o]x?ration l>e skilfully performed no harm, even 
if no gofx], results. Field states that in some of the cases in which 
paracentesis fails to give relief this is V>ecause Politzer's bag has not 



1 



304 DISEASES OF THE UPPER RESPIRATORY PASSAGES 



been used to dislodge the accumulated pus. After the acute symp- 
toms have ceased attention must still be given to the naso-pharynx, 
which commonly remains in a condition of chronic inflammation 
with lymphatic hypertrophy ; in children deafness may require the 
use of Politzer's bag at intervals for many months. Chronic dis- 
charge from the ear calls for treatment by warm mild antiseptic 
lotions carefully used, and the insufflation of boric acid in fine pow- 
der or of a powder consisting of equal parts of sodium chloride, 
bicarbonate, and biborate. During and after the acute attack en- 
largement of the lymphatic glands behind the angle of the jaw may 
call for attention ; of various local applications which may be used 
in the acute stage, probably belladonna fomentations are the most 
effective in preventing suppuration. 

Chronic pharyngitis in children is usually a sequel of repeated 
attacks of acute catarrh of the pharynx and naso-pharynx. The 




A.v. 

Adenoid vegetations of the naso-pharynx (drawn, from a post-mortem specimen prepared by 
Dr. A. T. Rake, by Miss M. Gordon, L.R.C.P. and S. Ed.). U, uvula. P, F', cut edges of soft pal- 
ate. A, V, adenoid vegetations. 

commonest form is granular pharyngitis. The earliest age at which 
I have seen this condition was in an infant aged four months. It 
becomes very common about two years of age, and after that age 
some 70 per cent, of London children of the poorer classes have 
granules in the pharynx. The granules are produced by swelling of 
the mucous glands with infiltration of the surrounding sub-mucous 
tissue. The intervening mucous membrane may be healthy, inflamed, 
or atrophied. The number of granules varies greatly, from two or 
three to twenty or more. They may be scattered irregularly or 
gathered into two bands which occupy the salpingo-pharyngeal fold 
(pharyngitis lateralis) ; in this situation the granules are partly hid- 



CHROyiC PHARYyCrlTIS. 305 

dvu by the pillars of the fauces, or bv the tonsils if enlarged, but 
come into view when the child swallows. The averaire size is about 
that of a split pea. If scattered, and few in number, they produce 
no symptoms, but if numerous they cause a sensation as of a foreign 
body in the throat, and constant hawking and coughing. These 
symptoms are more marked in lateral pharyngitis. They are much 
aggravated and may be accompanied by some ])ain on swallowing 
during the attacks of sub-acute catarrh to which the mucous mem- 
brane is in these cases greatly pi-edisposed. Cough may be very 
severe, and mucous exi>ectorati(>n in older children copious. Prob- 
ably two-thirds of the children supposed by their friends to be the 
subjects of chronic bronchitis are, in reality, suffering from granular 
pharyngitis. The condition is often associated with adenoid vegeta- 
tions of the nas<i-pharynx, but by itself does not produce anv ob- 
struction to respiration. After a time the repeated attacks of catarrh 
may lead to some sclerosis and atrophy of the intervening mucous 
membrane. 

When the granules are scattered and few in number they do not 
cidl for any treatment. They shrink gradually, become flattened, and 
finally disappear. AVhen numerous the discomfort in swallowing, 
the cough, and the frequent attacks of catarrh, render interference 
desirable. The only eifectual remedy is to destroy the centre of each 
granule with a fine galvanocauterv, if that be available. If it be 
not, a fairly satisfactory substitute is to touch each granule with Lon- 
don paste applied with a glass rod. It is a useful precaution to paint 
the throat with cocaine solution if the granules to be attacked are 
numerous or situated on the lateral folds. As a rule not more than 
half a dozen granules should be dealt with at one sitting. 

The adenoid tissue of the upper part and roof of the naso-pharynx 
is liable to hyperplasia, and chronic inflammatory changes analogous 
to those which produce granules in the pharynx. The overgrowth 
throws the mucous membrane into folds, as is well shown in the 
preceding illustration (Fig. 4Sj. This condition, to which the term 
adenoid vegetations is applied, may be present very early in life and 
may even, it is said, be congenital. The size of the nasal passages 
and of the naso-pharynx, however, varies very greatly in different 
individuals. When they are narrow, and when, as often happens in 
these cases, the palatine arch is high and narrow, and the anterior 
nares small or collapsed, an amount of adenoid overgrowth, relatively 
small, may block the air passage. An instance of this condition is 
afforded by the girl aged twelve, photographs of whom are reproduced 
in Figs. 40 and 50. She presents the '' adenoid facies," but the 
nasal obstruction is due in great measure, if not entirely, to the ex- 
treme narrowness af the nasal passages. 

The typical expression, the attitude, and some of the deformities 
20 



306 DISEASES OF THE UPPER RESPIRATORY PASSAGES. 



of the chest produced by adenoid disease are well shown in Fig. 51, 
from a photograph, for which I am indebted to Dr. StClair Thomson. 
The face wears a dull, heavy expression, the mouth is constantly 
open showing crowded irregular teeth, which, together with the gums, 
are in many cases dry and coated. The upper lip is caught up, the 
lower droops. The nose is pinched but clumsy, the nostrils narrow, 
owing to paresis of the alse nasi. The child is often deaf, owing to 
blocking of the pharyngeal orifice of the Eustachian tube. For the 
same reason there is a great liability, owing to retention of secretions, 
to otitis media. A transverse vein at the root of the nose is com- 
monly enlarged. 



Fig. 49. 



Fjg. 50. 





Nasal obstruction associated with congenital narrowness of the nasal passages. 

The adenoid overgrowth is almost invariably attended by catarrh 
and a muco-purulent, sometimes bloody, secretion, which may be 
seen on the posterior wall of the pharynx, and may escape from the 
nostrils during sleep, staining the pillow. 

The symptoms are inability to breathe through the nose, chronic 
" cold in the head,'^ noisy respiration by day, and snoring during 
sleep. The voice has a peculiar nasal, toneless, or " dead ^' character, 
and pronunciation is defective ; there is difficulty especially in pro- 
nouncing the nasal consonants n and m. 



H 



CHRONIC PHAEYSGITIS. 



307 



The reflex nervous symptoms attributed to adenoid vegetations are 
legion, and their enumeration would form a Kabehiisian catalogue 
of little practical value, since the evidence upon which the supposed 
connection is founded is commonlv verv insufficient. Two onlv 



Fig. 51. 




.\ boT, igfftX 4T4, suffering from adenoid vegetations of the naso-pharynx, showing the charac- 
teristic expre«-ion, attitude, and deformities of the chest. (P'rom a photograph in the possession 
(,f \tr >«f«^ lair Thorn. M-.n 



refill wortln* of mention : (1) The condition of mental dulne.ss and 
inability to fix the attention, to which Guye has given the name, 
aprosexia. It may Ix' com])ared with the '* stupid feeling" pr(>duccd 
by acute cor^za, and may very quickly disappear after operation for 
the removal of the vegetations. (2) Nocturnal enuresis, which may 



308 DISEASES OF THE UPPER RESPIRATORY PASSAGES 

certainly be aggravated if not produced by adenoid vegetations. 
The connection is probably to be found in the light, broken sleep 
from which these children snifcr. 

[A certain number of these cases, as well as some cases of enlarged 
tonsils (see below), are of a tubercular nature, and such are un- 
doubtedly the starting point of chronic tubercular processes, and are 
apt to be associated, as an etiological factor, with enlarged cervical 
glands.] 

The symptoms having suggested the presence of adenoid vegeta- 
tions, the diagnosis may be confirmed, or perhaps negatived, by in- 
spection or by introducing the finger behind the soft palate, with 
the pulp forward. The convoluted folds of mucous membrane will 
then, if present, be felt, ^^like a bag of worms.'^ 

If the overgrowth has attained dimensions sufficient to produce 
definite symptoms, especially any notable interference with respira- 
tion, the only effectual treatment is to scrape away the redundant 
folds. This operation should not be postponed in the hope that the 
child will ^^grow out of '^ the adenoids. It is true that the ob- 
struction to respiration becomes less as the naso-pharynx becomes 
more roomy, but this process is retarded by the loss of function due 
to adenoid vegetations. Moreover, the continuance of the obstruc- 
tion during the early years of growth of the chest may entail irre- 
mediable deficiency in its development and permanent deformity 
(Fig. 51). There is a difference of opinion as to whether the child 
should be given an anaesthetic for this operation, but in my experi- 
ence as much, or rather, as little, good can be done by scraping 
away at the time of examination, as much as the finger-nail can de- 
tach, as by any more elaborate operation without an anaesthetic. In 
well-marked cases such imperfect operations are not to be recom- 
mended, since they are almost invariably followed by recurrence. 
Cure depends on the production of a sufficient area of raw surface to 
ensure a good deal of cicatricial retraction. The main risks of the 
operation are the entry of blood or detached vegetations into the air 
passages (which may be minimized by keeping the head dependent) 
and septic basal meningitis. The operation should, therefore, not 
be undertaken until the general health has been got into as good a 
condition as possible, and until the local condition has been improved 
by astringent and antiseptic applications where this is found possible, 
though the small size of the naso-pharynx often renders their appli- 
cation very difficult. After the scraping, antiseptic douches (boric 
acid) should be used. 

Chronic tonsillitis is the term commonly applied to a condition 
of enlargement of the tonsils, due to overgrowth of the lymphoid 
tissue with attendant fibroid hyperplasia. It is secondary to repeated 
attacks of pharyngeal catarrh or tonsillitis, and is in some cases as- 



DEFORMITIES OF THE CHEST. 309 

sociated with, if it be not directly due to, the presence of tubercle 
bacilli. [On the other hand, many of these cases are but manifesta- 
tions of rheumatism, and, as mentioned above (see cha}>ter on 
Rheumatism), necessitate careful watchinjj for other manifestations of 
this diathesis, especially endo-j^>ericarditis.] The enlargement may 
be so great that the tonsils meet in the middle line. The lymphatic 
glands near the angle of the jaw are enlarged secondarily in most 
aises, and the distortion of the neck thus produced may be con- 
siderable. The tonsils are at first soft, but in time may become ex- 
ceedingly hard. The surface may be smooth, or coarsely granular. 
The mucous membrane may appear healthy, or it may be in a con- 
dition of chronic catarrh, with much mucous secretion, and accumu- 
lation in the lacuna^ of offensive cheezy matter which may eventually 
become calcified (tonsillar calculus). 

The symptoms are a sensation of a foreign body in the throat, 
chronic cougli, nasal voice, breathing through the mouth, and snor- 
ing during sleep. The breath is often foul, owing to decomposition 
of the cheesy masses in the crypts. The patients are very liable to 
catarrh of the pharynx, with consequent increased swelling of the 
tonsils, aggravation of all the symptoms, and free expectoration. 

As in the case of adenoid vegetations, all kinds of reflex nervous 
SNinptoms have been attributed to chronic enlargement of the tonsils. 
The most important secondary effect, however, is the deformity of 
the chest described below, to the production of which tonsillar hy- 
pertrophy appears to contribute. 

The only effectual treatment is tonsillotomy, that is to say, the re- 
moval of the most prominent part of the enlarged gland. It is fol- 
lowed by cicatricial contraction. Local applications may subdue in- 
tercurrent catarrh, but have not the least effect on large hard tonsils. 
If operation is refused they may \ye recommended as prophylactics 
against catarrh and consequent increased fresh enlargement of the 
tonsils. Tonics, iron, and cod-liver oil, and change of air may be 
advised, and if the nutrition is well maintained, and the child gets 
plenty of exercise in the ojxmi air, the tonsils eventually shrink, and 
as the naso-pharynx enlarges, cease to obstruct respiration. The 
danger is, hf>wever, that the development of the chest, and of the 
frame generally, may receive a check from which it never recovers. 

Deformities of the chest produced by ii<ii<o-phfirj/nr/c(i/ fthnfmc- 
tions. — The obstruction to respiration produced by overgrowth of 
the adenoid tissues of the naso-pharynx leads in a large number of 
cases to deformities of the chest walls. These changes are particu- 
larly marke<l in children who suffer also frf)m rickets. The com- 
monest defi»rmity is (1) ])igeon-breast. The lower and lateral parts 
of the chest are retracted during inspiration by the diaphragm, so 
that a horizontal groove is produced, while the sternum is thrust 



1 



310 DISEASES OF THE UPPER RESPIRATORY PASSAGES 



forward, and often bent at the junction of the manubrium with the 
body. A modification of this is (2) the so-called shoemaker's or 
funnel chest, in which the angle in the sternum is in the middle of 
the body, the lower part of the bone being pulled back, so that in 
some cases a deep hollow is formed. If the obstruction begin when 
the chest walls are more firmly ossified, the result is to produce (3) 
a long narrow flat chest (Fig. 51), the transverse diameter of the 
lower part is diminished, while the upper front is flattened, or even 
hollowed, a condition which undoubtedly predisposes to phthisis. 
In robust children, in Avhom the obstruction occurs after the age of 
eight or nine years, no deformity of the chest may ensue. If, how- 
ever, the obstruction is accompanied by attacks of asthma the lungs 
become emphysematous, and (4) the barrel chest is produced. 

Retro -pharyngeal abscess is not a common affection in infants, 
but it occurs in them more frequently than in children. Two classes 
may be distinguished : (1) the so-called idiopathic, which may be a 
sequel of measles or scarlet fever, or of stomatitis, tonsillitis, or 
disease of the naso-pharynx, though more often no cause can be as- 
signed ; and (2) tuberculous abscesses, secondary to vertebral caries. 
The suppuration occurs in the connective tissue outside the pharynx. 

The early symptoms — restlessness, an expression of pain during 
suckling and its sudden cessation followed by crying, are not charac- 
teristic. After a time, perhaps a week or ten days, the breathing 
becomes snoring, especially during sleep, which is much disturbed, 
suckling is more difficult and more evidently painful, and milk is 
returned through the nose. The infant breathes through the nose, 
and respiration is labored, so that the symptoms resemble those of 
laryngitis ; but the voice is usually unaltered. In some cases there 
is torticollis. Examination of the pharynx shows at first only gen- 
eral redness and catarrh. Dyspnoea and distress may be severe, and 
there may be some cyanosis of the face and distension of the jugular 
veins before a localized swelling can be seen on the front of the verte- 
bral column, usually in the middle line. A confident diagnosis can 
only be made when a soft swelling can be felt with the finger in the 
pharynx. It is round or oval, and conveys to the finger the sense of 
fluid contents. If left to itself the abscess may burst into the pharynx, 
and flood the larynx, causing sudden death. Early incision is there- 
fore imperative, and gives immediate relief. The left forefinger placed 
against the lower edge of the swelling should be used as a guide, and 
the incision made with a tenotomy knife. As soon as the incision, 
which should be half an inch long, has been made the infant should 
be turned on its face, so that the pus may flow out of the mouth. 
Only in rare cases has the abscess been known to fill again, but cases 
of burrowing septic abscess occur. As a rule, the diagnosis, when 
once the abscess has attained sufficient size to be recognized by the 



n 



RESPIRATORY SPASM. 311 

sight or linger, is easy, but when, as hapj)oiis in rare cases, it is sitii- 
ateti low down, it becomes a matter of great ditliciilty, since it is 
almost impossible to get a view of the parts, and the diagnosis must 
be made by touch alone. .Vn abscess due to caries is a more chronic 
at!\vtion. may present in the neck, and can best be treated by ex- 
ternal incision. 

Respii'atory Spasm. 

Children are liable to certain disturbances of the nervous mechan- 
ism of respiration, which produce symptoms of an alarming, and 
sometimes even of a dangerous, character. 

There is a f(n'm of infantile respiratory spasm, however, to which 
the term congenital laryngeal stridor is applied, though it is not 
always truly congenital, which does not endanger life nor interfere 
with growth.^ At birth, or within the first fortnight of life, the in- 
spiration is noticed to be noisy, hoarse, or croaking, ending sometimes 
in a short ci-ow ; expiratiiMi is silent, but may be grunting. There 
is recession of the epigastrium and the lower part of the chest, the 
alae nivsi may move, but there is no cyanosis and no distress. The 
stridor is not constant, it varies in degree, may disappear altogether 
for a time, or may be interrupted from time to time by full, long, 
noiseless inspirations. Excitement increases the stridor, but it dis- 
apj>ears or becomes much less marked when the child cries. Sleep 
diminishes and, when sound, stops the stridor. The infant can 
breathe through the nose, and sucks without difficulty. The stridor 
is probably due to some defect in the higher nervous centres, pro- 
ducing incoordination, or spasm of the laryngeal muscles. In some 
cases there is an undue backward curvature of the epiglottis, which 
has been considered by some to be a cause, by others a consequence, 
of the stridor. The stridor may occur (piite independently of laryn- 
geal catarrh. It is not related to rickets, and cannot be connected 
with tetany with any confidence, though carpo-pedal contractions 
occiir in some cases M-hen the stridor is greatest. 

Respiratory spasm in children is a paroxysmal affection nearly 
always associated with rickets, often with tetany, of which it may be 
the earliest .symptom. The attacks sometimes end in, or alternate 
with, convulsions. 

lieyond the almost invariable association with rickets^ nothing can 
V*e siiid definitely as to its etiology. In some cases there is laryngeal 
spasm only, but in the more severe forms there is complete tem|)o- 
rary arrest of all the movements of respiration, due apparently to an 
inhibition of the respiratory centre. 

' Dr. .lohn Thomson has ^iven an excellent description of the condition in the 
FjUnhurfjh Mrflirril Journal (Sept., 1892). 

' Bull found in 10^) ca-^es of spa^jui, unmistakable sijirns of rickets in 94, and more 
doubtful indications in 3 others. Jnhrh. f. Kiiuicrfilhtfr, Ikl. xxxvii., S. 401. 



312 DISEASES OF THE UPPER RESPIRATORY PASSAGES, 

Very frequently the attack comes on when the child wakes, and 
nic/ht terrors are often due to this cause. It may be provoked by 
crying, as is the paroxysm of whooping-cough, by coughing, by hic- 
cups, by any alarm, or by exposure to a cold draught of air. The 
paroxysms may occur as often as twenty times in the twenty-four 
hours. During attacks of inspiratory stridor the sterno-mastoid and 
other accessory muscles of respiration are in violent action, and there 
is recession of the epigastrium and the lower parts of the chest. 
Emphysema of the upper and anterior parts of the lung, and collapse 
of the lower may thus be produced, and favor the occurrence of 
broncho-pneumonia to which such children, owing to their rickety 
condition, are already predisposed. A severe attack produces much 
exhaustion and the frequent repetition of such attacks endangers life. 
The nature of the paroxysms varies in different cases. The com- 
monest form is a slow prolonged expiration followed by a normal in- 
spiration. A slight attack, such as this, causes the child little dis- 
tress, and may even pass unperceived by the friends. The next most 
frequent form is the converse of this — that is to say, a normal ex- 
piration is followed by a prolonged inspiration. The inspiration may 
be attended by spasm of the glottis-closers, and when this is suffi- 
ciently severe it is accompanied by a long, high-pitched, crowing note. 
The term laryngismus stridulus is applied to the forms in which this 
occurs. In some cases both expiration and inspiration are prolonged. 
None of these forms are immediately dangerous, though the loud in- 
spiratory cry is alarming. More alarming, and more immediately 
dangerous, since sudden death has often occurred, are cases in which 
expiration is followed by a prolonged pause during which the chest 
is motionless, and the face grows rapidly cyanosed. This may end 
in a free inspiration with or without the crowing sound (with which 
all immediate danger ceases), or by very imperfect attempts, short 
or long at inspiration, during which there is no sound, the chest walls 
recede and the muscles of the mouth and the alse nasi work. 

The prognosis depends upon the frequency and severity of the 
paroxysms. It is not good when they are numerous and severe, 
owing to the exhaustion which they produce and the liability to in- 
tercurrent affections of the lungs. The paroxysms, at first slight, 
may become more serious, and the possibility of sudden death from 
asphyxia and of the occurrence of general convulsions should not be 
hidden from the parents. 

The diagnosis is usually easy if the child can be seen in one of 
the attacks. The absence of laryngeal catarrh and coryza, the more 
chronic course, and in many cases the expiratory character of the 
spasm, will serve to distinguish respiratory spasm from the laryngeal 
spasm of croup. Whooping-congh, owing to the history of infection, 
the regular stages by which it develops, and the special characters 



RESPIRATORY SPASM. 313 

f the cough which precedes the inspiratory spasm can hardly be 
mistaken tor the respiratory spasm here described. 

Treatment during the attack cannot be very ctfectual. The clothes 
should be loosened, cold water sprinkled on the face and chest, and 
the skin chafed with the hand. If a hot bath is available the child 
should be put into it, and a douche of cold water poured over its 
chest. Between the attacks sedatives, such as ])otassium bromide or 
chloral, are of little use, though when the child is having attacks 
very frequently they may be of some temporary advantage. Henoch 
prefers opium or morphine (gr. J or more according to age), the hv- 
drochlorate or acetate of morphine. The main indication is to treat 
the underlying rickets {q. v.). 



CHAPTER XXVI. 

ACUTE BRONCHITIS, BRONCHO-PNEUMONIA, AND 

PNEUMONIA. 

Acute Bronchitis and Broncho-pneumonia : Pathology ; Symptoms ; Prognosis 
Treatment — Acute Lobar Pneumonia : Etiology ; Pathology ; Symptoms ; Com 
plications ; Diagnosis ; Treatment. 

Acute bronchitis and broncho -pneumonia, which are among th( 
most serious and common diseases of childhood, are very closely re- 
lated to each other clinically and pathologically. Both occur with 
great frequency as complications of measles, whooping-cough, diph- 
theria, and other acute infectious diseases. In many cases, in which 
they are apparently primary, they are preceded by coryza, pharyn- 
gitis, or tracheitis. The extension of the inflammatory process is asso- 
ciated with the spread of one or more micro-organisms. In bronchitis 
the microbes found most commonly are the staphylococcus pyogenes 
and the streptococcus pyogenes ; in broncho-pneumonia the pneumococ- 
cus of Fraenkel, and the pneumobacillus of Friedliinder. But the 
microbes which most often cause bronchitis may, under circumstances 
favorable to their entry into the alveoli, produce pneumonia, and 
the pneumococcus and the pneumobacillus may cause only bronchitis. 
Children attacked by bronchitis have often suffered for some time 
from gastro-intestinal disturbance with diarrhoea of offensive mucous 
stools. The diminished power of resistance due to the deterioration 
of general health produced by gastro-intestinal disease no doubt 
favors the development of bronchitis or broncho-pneumonia, and in 
other circumstances it is not to be assumed that either is always, 
or indeed commonly, to be traced to infection from a previous case. 
The bronchial or pulmonary tissues damaged by debilitating disease, 
by the inhalation of irritants, or by the changes induced by exposure 
to cold, easily become infected. One or more of the varieties of the 
microbes commonly associated with acute bronchitis or broncho-pneu- 
monia are present in the mouth in a large proportion of all cases 
examined. Further, these microbes are to be found in overcrowded 
rooms, and may be conveyed from one person to another by drinking 
vessels used in common, especially in hospitals and asylums. Thus 
is to be explained the extreme frequency and severity of broncho- 
pneumonia among children suffering from measles and whooping- 

314 



ACUTE BROyCHITIS AXD BROycHO-PyEUMONIA. 315 

cough, iiursoil in overcnnvcUHl tononionts ov in in>titiitions in which 
special precautions are not taken to avoid int'ection. 

Pathology. — Acute bronchitis may affect any part of the bronchial 
tree, and is more serious the finer the bronchi involved. To the 
most severe cases, in which the finest bronchi are involved, the term 
capiUary bronchitis has been a})plied, but it is probable that in all 
these cases the alveoli are also attacked, and that we have to do 
with broncho-pneumonia added to the bronchitis. In broncho- 
pneumonia there is a general inflammation of all the tissues of 
the lung — the bronchi, pulmonary alveoli, and lymphatic system, 
and if the part affected be near the surface the pleura also may be 
involved. At the same time there is more or less inflammation of 
the large bronchi, and of the medium bronchi in many other areas 
than those in which consolidation occurs. In fact, bronchitis, con- 
gestion of the pulmonary tissue, and areas of consolidation are pres- 
ent tojrether, but in varvin^ deoTce and extent in different cases and 
in different parts of the lungs in the same case. Thus the whole or 
greater part of a lobe may be consolidated, while in other parts of 
the same hmg and in the other lung we find bronchitis with, as a 
rule, disseminated patches of lobular pneumonia. Some enlargement 
of the bronchial lymphatic glands necessarily attends bronchitis and 
broncho-pneumonia, and chronic adenitis may remain as a sequel. 
The presence of these enlarged glands appears to favor recurrence 
of bronchitis. In many cases these glands become tuberculous, and 
in some at least the tuberculous adenitis is the primary lesion to 
which recurrent attacks of bronchitis or broncho-pneumonia are sec- 
ondary (see p. 169). 

In firnfe bronchitis there is at first hypertemia, and serous infiltra- 
tion of the bronchial mucous membrane, which becomes swollen but 
remains dry. Upon tliis condition ensues diapedesis, with accumu- 
lation of leucocytes beneath and between the epithelial cells, detacli- 
nient in greater or less num])ers of ciliated cells, increase in the 
number f)f mucous cells, swelling of the mucous glands and copious 
.secretion from these sources. The surface is tiius rendered moist, at 
first by a tenacious mucous, and later by muco-])urulent, material. 
Wlien the inflammation is persistent it may involve eventually the 
l»ronchial muscles and the elastic tissue, and tiius determine more or 
h'ss extensive and permanent dilatation of the bronchi. In slight 
cases the trachea and large bronchi only arc involved ; in more 
-cvere, the medium bronchi, also; ami the most severe the 
smallest bronchi, pn>ducing 'W^apillary bronchitis," which, on 
account of the rapidity with which severe symptoms develop, is 
sometimes calle<l ''suffocative." The infective j)rocess extends 
Hience to the jiulmonary alveoli, and it is probal)le that capillary 
•ronchitis is always accompanied by .some alveolar catarrh, which, if 



316 BRONCHITIS, BRONCHO-PNEUMONIA, PNEUMONIA. 

death docs not occur at an early date, passes on quickly to distinct 
hroucho-pncumonia. The inflammation may extend not only, as 
above described, by contiguity, but also by inspiration of infective 
secretions. During the deep inspirations which precede and follow 
cough infective muco-purulent matter in the larger bronchi may be 
sucked down into the smallest, and there start inflammation of the 
lobule. Such a plug of mucus may act as a valve, permitting some 
air to escape during expiration, but preventing entrance during in- 
spiration. In this way all the air may be expelled, and the lobule 
collapse. Apart from any valvular action, if a plug occlude a bron- 
chiole, the air is then absorbed from the lobule which therefore col- 
lapses. This condition of atelectasis is an important factor in 
broncho-pneumonia, since the collapsed lobules easily become in- 
volved in the inflammation of neighboring lobules, or infected 
from the plug of mucus. Atelectasis is favored by any condi- 
tion which renders full expansion of the lungs difficult — by the 
congestive thickening of the mucous membrane and the tenacious 
secretions produced by bronchitis, by the thoracic deformities of 
rickets, and by prolonged lying on the back in one attitude. It oc- 
curs most frequently at the borders of the lungs, especially the lower 
border, but often involves large areas in the posterior portion of the 
lower lobe. The collapsed area is sunk below the general surface of 
the lung, is of a dark red or purple color, and shows a uniform red 
surface on section. It sinks in water, but can be insufflated unless 
inflammation have already commenced. 

Acute bronchitis varies much in severity. In a case of moder- 
ate severity the child, after perhaps suffering for a day or two from 
coryza, begins to have a dry cough, the breathing is a little hurried 
and labored, the pulse is quickened, and the temperature is raised, 
touching 100° or 101° F. at night. The child is restless and thirsty, 
but refuses food. The skin is moist and the face flushed. The 
chest expands w^ell, and there is no dulness on percussion ; on 
auscultation sibili are heard here and there, especially at the back, 
but are often masked by a loud rhonchus which has its point of 
maximum intensity over the large bronchi in the interscapular re- 
gion. The sounds are inconstant, rhonchus may disappear after 
cough, and the points at which the sibili are heard may change in 
the course of a few minutes. As secretion from the mucous mem- 
brane begins the sibili give place to loose mucous rales, but as a rule 
children under five years do not expectorate. In a more severe case 
the inspiration is more hurried, the sibili of the early stage are 
heard in all parts of the chest, and are more constant, and the 
mucous rales of the later stage are smaller and more numerous. It 
is useful to bear in mind the dictum of Graves that the more 
numerous the sounds heard at anyone point to which the stethoscope 



ACUTE BROSCHITI^. 317 

is applied the smaller the bi*onehi involved. The pulse is rapid, 120- 
l.")0, and the laee may be pale, or even slightly eyanosed, and the 
lips bluish. The temperature reaehes its highest daily point gener- 
ally in the evening; it may be 102° or 10:]'', or only 100°"F. or 
less. A low temperature is an unfavorable sign, generally observed 
in eacheetie children. In these, and especially in riekety children, the 
expansion of the lower part of the chest may be defective, so that 
there is recession in the lower axillary regions, in the episternal 
notch, and in the epigastrium. The recession is greater when there 
is laryngitis, or obstruction of the trachea and larger bronchi by 
tenacious mucus. Much recession generally means some collapse, 
and with collapse we are on the verge of broncho-})neumonia. 

The prognosis, both as to recovery and as to duration of symptoms, 
varies greatly. In a well-nourished child the symptoms may reach 
their maximum in a couple of days, and begin rapidly to subside in 
two or three days more, so that the patient is convalescent at the end 
of a week. In other cases, especially in cachectic children in whom 
the primary systemic reaction is not well marked, a condition of 
subacute broncho-pneumonia is very apt to supervene, and the case 
may drag on for weeks or mouths, or chronic bronchitis may become 
established. 

It is often impossible to say when acute bronchitis becomes com- 
plicated with broncho-pneumonia. AVhen the child has been suffer- 
ing previously from no more than a subacute attack of bronchitis, the 
onset of the pneumonic complication is more easily distinguished. 
The child is noticed to be peevish and restless, changing its attitude 
at short intervals. The cheeks are flushed, the skin dry, and the 
rapidity of respiration is increased. There is a loose cough, and the 
child cries a good deal ; it refuses food, but suffers much from thirst. 
At night all the symptoms are aggravated and the temperature rises 
to 102°, 103° F., or even higher. The alae nasi move, and inspec- 
tion of the chest shows that some of the accessory muscles of respira- 
tion are in action. At one or more points, most often near the 
angle of the scapula or at the base, sub-crepitant rales may be 
heard. These are often obscured by rhonchi and sibili in the larger 
bronchi. A little later the respiration over this area becomes bron- 
liial ; while sub-crepitant rales may l>e heard in other jiarts of the 
liest. The signs of consolidation are generally more pronounced (»n 
ne side, but are commonly present on both. Vocal resonance is in- 
reased, and it is possible to detect some diminished resonance on 
jKjrcussion. 

But the onset af broncho-pneumonia may be very much more 
acute. A child, after suffering for some days from an attack of 
bronchitis not presenting features of special severity, is seized sud- 
denly with dyspnoea and a short painful cough. Tlie face is pale. 



318 BRONCHITIS, BRONCHO-PNEUMONIA, PNEUMONIA. 

with a dusky blueness about the nose and lips. The expression is 
anxious ; the eyes prominent, and the nostrils dilate with each in- 
spiration. The child, if old enough to sit up, leans upon its hands, 
and all the accessory muscles of respiration are called into action. 
All its energies are absorbed in attempting to get air into its lungs, 
and it does not interrupt these efforts to cry. From time to time 
the accumulation of mucus in the large bronchi and trachea renders 
the breathing more or less stertorous. Presently, by a short choking 
cough, the mucus is dislodged, and swallowed, and the child puckers 
its face as though about to cry, but seldom makes any sound. Res- 
piration is very rapid, reaching perhaps 80 in the minute, and the 
pulse runs up to 140 or 160. The skin is dry and pungent. The 
child refuses food, takes little notice of its surroundings, and sleeps 
little, if at all. Physical examination of the chest commonly fails to 
reveal pulmonary changes sufficient to account for the violence of the 
symptoms. Sub-crepitant rales may be heard over large areas of the 
back and axillae, but the percussion note is little if at all impaired. 
A condition of such extreme gravity and distress cannot long be 
endured. The circulation begins to fail, the face becomes gray and 
haggard, the eyes glassy, the skin cold and perspiring. The pulse 
grows quicker, 160 to 180, irregular, and often uncountable at the 
wrist. Respiration becomes more shallow and less and less effectual, 
while mucus accumulates in the larger bronchi. Finally, the child 
grows drowsy, and passes into a condition of somnolence which ends 
usually in death. 

The prognosis of broncho-pneumonia depends in part on the extent 
of lung involved, in part on the general condition of the patient be- 
fore the attack, or on the nature of the general disorder which it 
complicates, and in part on the patient's surroundings. In cases of 
the type last described the prognosis is very unfavorable, as the im- 
mediate danger to life is great, and even in those in which the 
symptoms are less severe, and the physical signs more limited, the 
course is very variable. In some cases the symptoms and physical 
signs clear away in a week or a fortnight. In others in which they 
continue with alternate remissions and exacerbations for a month or 
more the question whether the broncho-pneumonia be not really 
tuberculous will arise, but will often be difficult, in fact, impossible, 
of solution, unless the progress of the case can be watched for some 
time. In the more prolonged cases death is brought about rather 
through exhaustion than by the intensity or extent of the disease. 

Treatment. — A child suffering from even slight acute bronchitis 
should be kept in a well-warmed room, which should have as little 
furniture as possible ; the air should be kept free from dust, and, if 
necessary, moistened artificially. A laxative or purgative should be 
ordered, and a simple linctus containing ipecacuanha. 



ACUTE BROyCHlTIS. 319 

[Alkaline: V in i Ipecac, ^iij-vj 

Pot. Bicarb., gr. lij 

Aq. Anethi, 5J 

Appendix.} 

Hot fomentations, if skillfully appliod at the onset and renewed two 
or three times, often give relief. Free perspiration may be provoked 
in robust children, who should, however, under these circumstances 
be kept strictly in bed. The child may be given warm drinks, such 
as h(^t milk diluted with water ; or, in the houses of the poor, weak 
tea with milk, or the old-fashioned remedy — camomile tea. In any 
case the draught should be copious and hot. Spirit of nitrous ether, 
formerly a favorite domestic remedy, operates in a similar manner. 
Superior to all these is a hot bath for twenty minutes, starting at 1)5° 
F. and raised to 104° F. After it the patient should be dried 
quickly with a large rough towel, put into a warm bed, and wmpped 
up in a blanket, which may be withdrawn in an hour. Or the bath 
may be followed by a warm pack. The routine practice of giving 
expectorant drugs at all stages of bronchitis is not to be commended. 
In the earliest stage, when the chest is full of sibili, ipecacuanha will 
afford relief to the feeling of tightness ; the best way to administer 
it is in small doses (for a child of one year, 111iij-v) every two hours 
for ten or twelve doses. At a later stage, when numerous mucous 
niles are to be heard in all parts of the chest, ipecacuanha and other 
expectorants are useless or, rather, so far as they have any action, 
hanuful. The difficulty at this stage is in the expulsion of the large 
amount of mucous secretion forme<:l. Diffusible stimulants are open 
to the same objections ; the best stimulant, when it becomes necessary 
to administer one, is alcohol — brandy, champagne, mulled claret, 
egg-nog, or the brandy mixture of the B. P. Opium and morphine 
should be usckI with great caution, but can not render important ser- 
vice in the treatment of bronchitis in the latter stages, when respira- 
tion is obstructed by mucous accumulations, and when the cough 
occurs in jxiroxysms or is so frequent as to prevent sleep. A con- 
venient remedy is the comjwund camphor tincture, to the amount 
of about ITlxx in twenty-four hours, in six doses (for a child one 
year old), or the hydrochlorate of moi-phine in solution, or a single 
dose in powder in the evening. 

[(The compound camphor tincture may be given as follows :) 
T. Camph. Co., ^ij->v 

Acid. Hydrochlor. Dil., TT\j 

Vin. Ipecac., TT\^iJj-v 

Glycerin., v\,x 

Ad. Cam., ad 3.1 

Appendix.] 

In the early stage, in place of ipecacuanha, antimonial preparations may 
be used. Apc>moq)hine also is highly recommended as an expectorant. 



320 BRONCHITIS, JBRONCHO-PNEUMONIA, PNEUMONIA. 

[Aporaorphine Linctus, 
Aporaorpliine Hydrochlor. , gr. ^ 

Acid. Hydrochlor. Dil., TT\^j 

Svrup. Limon., 9j 

Aq., ad 3j 
For children over 8 years. Appendix.] 

When moist sounds in the chest show that there is much mucous 
secretion^ children old enough to understand should be encouraged to 
cough ; younger children should be induced to shift their position, or 
taken out of bed Avrapped up in a blanket to promote coughing. 
Very young children do not expectorate, bu^ the mucus expelled from 
the air passages is swallowed. Young and feeble children should not 
be entirely confined to bed, nor permitted to remain too long in the 
recumbent attitude. When the amount of secretion is very large an 
attempt may be made to induce vomiting should the general condi- 
tion not forbid it. For this purpose a large dose of ipecacuanha 
(3j of ipecacuanha wine, or ipecacuanha in powder with tartarated 
antimony) may be given. It is not always easy to induce vomiting, 
nor wise to repeat the dose. If vomiting does not ensue, the child 
should be taken up, the tongue depressed and the fauces tickled, in 
the hope that the mechanical stimulus may reinforce the action of the 
drug. Jiirgenson recommends strongly the hypodermic injection of 
apomorphine. 

Severe bronchitis, the so-called capillary bronchitis (which prob- 
ably always means bronchitis associated with broncho-pneumonia), 
should be regarded as a very serious disease, calling for most careful 
treatment. 

In broncho-pneumonia the fever rarely in itself constitutes a danger, 
and the use of antipyretic remedies is not to be recommended. All 
drugs belonging to this class, with the exception, perhaps, of quinine, 
have a depressing effect upon the heart, and the danger to life is in a 
breakdown of the heart and of the nervous forces. The liability to 
pulmonary collapse must be borne in mind, since it is both dangerous 
in itself and a precursor of extension of the pneumonia. Infants and 
young children should not be left for long hours motionless in bed. 
They do much better in a nurse's arms, since in practice this involves 
frequent shifting of position. A warm bath (80° to .85° F.) should 
be given for fifteen minutes; or a hot bath (95° to 97° F.) for a 
rather longer time. The good effect of the bath may be judged by 
the diminution in the respiratory rate. If the child be robust and 
not exhausted, from half a gallon to a gallon of water at a tempera- 
ture of about 65° F. may be rapidly poured over the chest before the 
child is removed from the bath. This will induce deep respiration, 
followed, probably, by a fit of coughing. The bath may be repeated 
twice or thrice in the course of the twenty -four hours. The tempera- 



ACUTE BRONCHJTIS. 321 

tare of the bath and of the water iisetl for the eool douehe at its end 
may be varied aeeording to the etfect produeed. If exhaustion 
already exists when treatment is eonuneneed, or if the ehikl be 
slightly eyanosed, the general eold douehe should be replaced by a 
sti-eam of cool water poured on the nape of the neck, about the verte- 
bra prominens, from the spout of a kettle or from an india rubber 
siphon, for ten or twenty seconds. When removed from the bath 
the child should be rapidly dried with a rougli towel, dressed in a 
flannel nightgown, and put into a warm bed. 

The baths may be replaced by a wet pack, which is always to be 
prefemxl in weakly children. The temperature of the water used for 
making the pack and the extent of the body to be covered by it must 
be determined by the general condition of the child : and good results 
may be obtained in cases of moderate severity by the cold pack ap- 
plied r<iund the chest alone. In children of robust constitution, with 
high temjx^ratureand signs of extensive broncho-pneumonia, the pack 
may be wrung out of ice-cold water, or an ice poultice may be applied 
to the chest ; but its effect must be carefully watched, and the method 
should not be used unless the patient is under frequent observation. 
Under similar circumstances, dry cupping over the part most affected 
is often followed by much improvement in the breathing. In the 
early stage, when the face is flushed and sibili predominate in the 
lungs, a steam-tent over the bed often gives relief; but it is not de- 
sirable to continue its use indefinitely. 

Expectorant remedies also are generally beneficial in the early 
stage, especially ipecacuanha, given in the manner recommended 
above. The child should be carefully fed at regular intervals, the 
best food being milk diluted with seltzer water or barley waiter, and 
in older children egg beaten up with sherry or brandy and water 
(about half an egg to a dessertspoon of sherry or TTlxxx of brandy). 
Infants at the breast, owing to the dyspnoea, are commonly unable to 
obtain a sufficient quantity of milk, which must be drawn off and ad- 
ministered in a spoon. The great danger is heart failure, and against 
this, unfortunately, little can be done. Caffeine, either by the mouth 
or hypodermically, or subcutaneous injections of camphor, may be of 
service. 

In children beyond five or six years old strong coffee, to 
which a small quantity of cognac is added, may be of service. 
When the child is tending to recover, the (piantity of nourish- 
ment given should be increased, and it should, if possible, be 
moved by day into a second room, which has previously been well 
warmed and aired. It is advisable to begin the administration of 
cod-liver oil at as early a date as possible, and in children who are 
already habituated to this remedy, it may be given as swn as the 
temperature falls. 



322 BRONCHITIS, BRONCHO-PNEUMONIA, PNEUMONIA. 

Acute lobar or fibrinous pneumonia {pneumonic feverf is a 
specific inflammation of the lung due to infection by the pneumo- 
coccus. The lung is not the only organ which may be infected by 
this microbe ; pericarditis, endocarditis, meningitis, laryngitis, and 
otitis may be produced by it, either independently or, more com- 
monly, as complications of pneumonia. As already said the pneu- 
mococcus may produce either broncho-pneumonia or lobar pneumonia, 
but affection of the whole lobe of a lung, or more than one lobe, by 
the acute inflammatory process gives rise to a clinical type of disease 
very well characterized in adults, and to be recognized, though its 
symptoms are often less typical, in children. 

Etiology. — The pneumococcus is present in the saliva of about one 
healthy person out of five, but in a much larger proportion, four in 
five, of those who have had pneumonia months or even years before 
the examination. The infection may be derived directly from a 
person suffering from pneumonia, and the disease may develop at 
once or after an indeterminate period, during which the pneumococcus 
remains in the mouth. The pneumococcus may retain its vitality for 
some time in articles of clothing or furniture soiled by expectoration ; 
in this way may be explained the so-called ^' house pneumonia," one 
case occurring after another in the same house. '^Family pneu- 
monia " (the predisposition of particular families) may be accounted 
for in part by the survival of the pneumococcus in the mouth of a 
person who has once had the disease and its transference to other 
members of the family, where it remains until these individuals are 
eventually subjected to conditions which favor the fixation of the 
pneumococcus in the lungs. 

Exposure to cold must be reckoned among the most important of 
the deterinining causes of cases of pneumonia not secondary to the 
acute infectious diseases. Secondary pneumonia occurs with greatest 
frequency after typhoid fever and influenza ; but it is not infrequent 
in association with diphtheria, scarlet fever, and erysipelas, and is 
occasionally a complication of small-pox and of acute rheumatism 
and malaria. These diseases determine the onset of pneumonia in 
two ways — by diminishing the resistance of the body and increasing 
the virulence of the pneumococcus. Cold, which can be recognized 
distinctively as an antecedent in a quarter or a third of the cases, 
probably acts reflexly on a lobe or lung, preparing it to receive the 
pneumococcus. Symptoms may set in within two or three hours of 
the exposure. A blow on the chest is the determining cause of a 
small proportion of the cases of pneumonia in the adult, and a fall is 

^ Pneumonia, by some modern writers, is classed among the acute specific fevers. 
It is specific in so far as it is due to a specific virus (the pneumococcus), but since 
this microbe is capable of causing inflammation of other organs and produces charac- 
teristic symptoms only when it aflfects the lung, and even then not always, since it 
may produce only broncho-pneumonia, it is more appropriately considered here. 



1^ 



ACUTE LOBAR OB FIBBISOUS PyEUMONIA. 323 

often mentioned as an anteeedent of the disease in ehildren. Foul 
and dusty air and sewer gas are also to be mentioned amono- causes 
w liieli may determine the onset of pneumonia. 

MoRHiD Anatomy. 

NAKKn EYK. M U KOSi oi'U A T.. 

I. — Staj^e of Eugorgeinent. 

I>eep red or purple, very moist on sec- i Great dilatation of capillaries of alveoli 
tion ; crepitates and exudes a frothy and bronchioles. Alveoli contain 

tiuid on squeezing. larsjc multi-nuclcatod cells, derived 

from the epithelium. 

II.— Stage of Ked Ilcpatizatiou. 

P»right red: solid, non-crepitating; Alveoli tilled with fibrinous exudation, 

in which are entangled red and 
white blood cells and epithelium 
cells. 



friable : granular on cut surface. 



III.— Stage of Grey Hepatization. 

< ireyish ; solid ; very friable ; yields a Fibrinous exudation broken up by inlil- 
yellow pus-like fluid. trating cells. When recovery is tak- 

ing place the cells are large and 
granular ; when destruction, there 
I are more small cells, which infiltrate 

j also the alveolar walls. 

All three stages may be present at tlie same time in the same lung. 
In children under five years the upper lobe is attacked almost as 
often as the lower (44 : 100), between five and ten years the propor- 
tion is 3s : KM). 

The pneumococcus is a small oval microbe occurring generally in 
«'<»uples embedded in an albuminous material, to which the term 
• capsule " has been applied. It is stained by Gram's method ; it 
_rows at temperatures over 24° C, forming on the surface of the 
• ulture-mediura fine, roundish, transparent mas.ses like dewdrops. 
It grows rapidly, and when growing in contact with oxygen, reaches 
its maximum development in about forty-eight hours. Its virulence 
and vitality thereafter diminish rapidly, and at the end of four or 
five days it ceases to be possible to start new cultivations. A typical 
attack of acute pneumonia terminates in a crisis, and it has been 
found that this coincides with a remarkable diminution in the viru- 
lence and number of the pneumococci present in the liuigs. This 
diminution in virulence is attributed to the combined action of the 
high body-temperature, of phagocytosis, of poisons formed by tiie 
pneumococci (antipneumot^jxin), and to the jiroduction of an acid 
reaction in the lung, the pneumococcus being unable to develop in 
acid media. 



324 BBO^^CHITIS, BRONCHO-PNEUMOl^JA, PNEUMONIA. 

The blood contains an excess of fibrine and an increased number 
of leucocytes. The leucocytosis corresponds with the temperature, 
and decreases with it. It is probably related to the phagocytosis 
wliich is the main element in bringing about recovery. 

The onset of symptoms is generally sudden, and marked by shiver- 
ing, convulsions, or in elder children by a distinct rigor ; epistaxis 
is not uncommon, and there may be severe headache. The symptoms 
develop rapidly ; the most constant is dyspnoea. The respirations 
rise to 40 or 50, even to 70 or 80, in a minute ; and the pulse-respira- 
tion ratio is altered. The upper accessory muscles of respiration 
come into play ; the lifting of the upper pait of the chest is often 
very marked, and the associated facial muscles are often thrown into 
action, causing expansion of the ala? nasi, lifting of the upper lip, 
and retraction of the corners of the mouth with each inspiration. 
The pulse at first seldom exceeds 140, but at a later stage it may 
become uncountable. The symptoms, as Avell as the physical signs, 
diifer, according as the pneumonia begins at the surface or in a 
deeper part of the lung; both are more characteristic in the former 
alternative. Stitch in the side, which is to be attributed to the in- 
volvement of the pleura in the inflammation, is present in about half 
the cases, and renders the cough, which is short and dry, painful, so 
that the child endeavors to avoid coughing, and often makes a short, 
grunting sound, apparently due to the suddenness Avith which in- 
spiration is ended, owing to the pain which it causes. [More com- 
monly the child locates the pain in the abdomen, generally at the 
epigastrium, and thus may direct our attention exclusively to abdomi- 
nal trouble if we do not remember this peculiarity.] The skin is 
hot and dry, and there is a bright red flush over the cheek bones, or 
over one cheek bone only. This one-sided flush is most often ob- 
served in pneumonia of the apex, and generally on the same side 
as the pneumonia. Sometimes the flush extends over the whole 
of the face and the upper part of the trunk, and may suggest scarlet 
fever. Herpes of the lip or chin may precede or accompany the 
onset of pneumonia, but more commonly it makes its appearance 
about the second day. The child is often drowsy by day, and rest- 
less or delirious at night. It has no appetite, but suffers from thirst, 
and the tongue is dry and furred, or aphthous. Diarrhoea may come 
on at the onset of the disease, or at the time of crisis. The liver 
and spleen are frequently enlarged, and jaundice may be met with, 
especially in some epidemics. 

The temperature rises suddenly, and when the patient is first seen 
may be 103° to 104° F. ; the fever is continuous, and morning re- 
missions are absent or little marked. Defervescence is commonly 
by crisis at some period between the fifth and eighth days, but the 
descent of the temperature curve is often more gradual. In either 



>i 



ACUTE LOBAR OR FIBRIXOUS PyEUMOyiA. 325 

ase the temperature may fall below normal. The erisis may bo ao- 
companieil by copious sweats, or by diarrhiva. The pulse tails aud 
the dyspncea diminishes greatly. During the attaek the urine is 
diminished in quantity, and contains less urea and phosphates, and 
also a smaHer quantity of toxins, than in health. At the erisis a 
very large quantity of urine maybe passed, and during deferveseenee 
the urine is eopious, e^^itains mueh urie aeid, and a large quantity of 
toxic matters. Albuminuria is not uncommon during the fever, but 
the amount of albumen is seldom large. 

Acute lobar pneumonia, esjx^eially when it involves the apex, is, 

;- a rule, attended by congestion of the iace, and there is some dull- 
ing of the intelligence, but the child can usually be aroused to answer 
ijuestions. In some cases the onset or the early stage of the fever 
is marked by convulsions, stujx>r, or delirium. This is the so-called 

•rrcbral pncumoiiid, ''hut it may be unaccompanied by any gross lesion 

I the brain or meninges. Convulsions, observed generally in infants, 
may not come on until the fourth or fifth day, and are preceded by 
stupor. They vary in severity from irregular movements and some 
rigidity of the limbs to general epileptiform convulsions. Stupor in 
its most developed form is seen chiefly in children of two to fivo 
years. In older children delirium may be violent, but is usually of 
the mild and muttering type. Generally both stupor and delirium 
disapj>ear on the third or fourth day. Ocular or facial paralysis war- 
rants the diagnosis of meningitis, though exceptions occur, and re- 
traction of the neck, though a very unfavorable element in j^rognosis, 
is not conclusive evidence of actual meningitis. The physical signs 
may be very marked or very slight. When well marked there is a 
slight diminution of expansion with inspiration on the affected side, 
though the side may be slightly fuller than the other ; there is dul- 
nessat one base or ai)ex, according to the part of the lung involved ; 
vociil fremitis is increased in this area, and respiration is hai-sh or 
l)ronchial or tubular, with small or fine crepitation at the end of in- 
spiration ; the voice sound is well conducted and has a metallic or 
bleating quality. At an earlier stage there may be no dulness, or 
the i>ercussion note may be actually tympanitic, while the respiratory 
sounds are merely feeble, with perhajis a few fine crepitations at the 
end of inspiration. In such a case the ])hysical signs will probably 
become well marked within twenty-four hfuirs. In others, again, 
witli symptoms which point strongly to pneum(»nia, no physical signs 

i' any kind can l)e discovered in the chest for days. This is com- 
monly attributed to the pneumonia being deejvseated. In doubtful 
cases search should he directed especially to the angles of the sea|)ulie, 
the intervertebral groove, and to the apex. In a well-marked case 
the breath sounds grow more and more tubular until, when hepatiza- 
tion is complete, the breathing is intensely harsh, or typically tubu- 



32G BRONCHITIS, BRONCHO-PNEUMONIA, PNEUMONIA. 

lar, but unaccompanied by crepitation. When resolution commences 
crepitations again begin to be heard, and become coarser and moister, 
until finally they obscure the breath-sounds more or less completely. 

Complications. — The serous membranes are specially liable to 
become infected during pneumonia. The infective agent is generally 
the pneumococcus, and the inflammation it produces is characterized 
by the large amount of fibrine in the fluid exuded, so that false mem- 
branes are often found ; by its richness in cells ; and by the bright 
yellow color of the pus. Occasionally the pneumococcus is replaced 
by or associated with streptococci or staphylococci. 

Pleurisy is an almost invariable accompaniment of lobar pneu- 
monia which reaches the surface. It is characterized especially by 
the formation of false membranes which vary in thickness, but are 
commonly thin and soft. As a rule, the quantity of fluid is small, 
but it sometimes increases as pneumonia subsides. Pericarditis is 
an occasional complication, commonly in association with pleurisy. 
The peritoneum may also be involved, the exudation being fibrinous 
or fibrino-purulent. The joints (especially the knee, shoulder, and 
thumb) may be attacked, as also the bursa, the inflammation result- 
ing in the production of greenish or yellow tenacious pus. Otitis 
media is a common complication, though often overlooked. It is 
frequently double, and causes symptoms which may be mistaken for 
meningitis. Perforation of the drum will occur in some cases, but 
symptoms may be relieved by a timely paracentesis. The prognosis 
as to the recovery of the ear is good, but the risk of mastoid abscess 
and meningitis is considerable. 

Meningitis not secondary to ear disease is a rare complication. 
Post mortem greenish-yellow soft fibrinous exudation is found chiefly 
along the course of the larger vessels. In many, perhaps the ma- 
jority of the cases, the meningitis affects the convexity of the brain, 
and is latent. There may be severe pain in the head, followed by 
coma, but not infrequently the spinal meninges are also involved, 
and rigidity and contraction of the neck are observed. Rarely the 
base of the brain is affected, and paralysis of some of the ocular 
muscles, facial paresis, and disturbance of the respiratory rhythm 
may be produced and cause the case very closely to resemble tuber- 
culous meningitis. 

The diagnosis of acute lobar pneumonia is often difficult at first, 
owing to the absence of definite physical signs [e. g., in " central ^' 
pneumonia] . The onset, in the midst of apparent health, of high 
fever, with rapid breathing, pungent skin, without any eruption or 
evidence of acute disease of the pharynx or larynx, and, when these 
are present, the unilateral flushing of the cheek, and herpes labialis, 
will raise a presumption of pneumonia ; later, the rapid spread of 
consolidation will increase the probability that the affection is lobar 



II 



ACUTE LOBAR OR FIBRIXOUS PNEUMONIA. 327 

and not lobular pneumonia, and the occurrence of crisis between the 
lifth and the eighth day will ooutinn the diagnosis, and warrant a 
favorable prognosis. [The atypical course of the disease is fully as 
•lumou as the typical, and careful daily explorations of the chest 
are absolutely necessary in obscure cases and will, in time, generally 
reveal the characteristic signs. This examination should be made 
with the stethoswpe, as with the unaidetl ear we cannot explore the 
chest with sufficient minuteness. In addition to the areas already 
mentioned, we must examine high in the axilla, where we will not 
infret|uently detect diagnostic signs. The signs elsewhere as well as 
here may be very slight indeed ; instead of dulness we may get only 
a sense of increased resistance to the finger on percussion, more 
'\isily detected in children on account of the thin chest-wall ; instead 
f the characteristic bronchial respiration we may hear only respira- 
tion slightly higher pitched than that on the unaffected side, at the 
corresponding point. These two signs have often been made out at 
tlie first visit to cases which, twenty-four or forty-eight hours later, 
showed the dulness and bronchial respiration of a typical lobar pneu- 
monia ; taken with other points, the sudden onset, vomiting, elevated 
temperature, quickened pulse and respiration, they are of great 
diagnostic imjwrtance. 

The diseases with which at the outset acute lobar pneumonia may 
be confused are, acute tonsillitis, scarlet fever, lobular pneumonia, 
cerebro-spinal meningitis and acute intestinal trouble. Examination 
of the throat will generally show the characteristic appearance of 
tonsillitis, and if the case be one of scarlet fever, may show the 
presence of the enanthem and excite suspicion of this disease. The 
suspicion of scarlet fever it may be impossible to confirm for a day 
or two, until the appearance of the characteristic exanthem. The 
beginning of lobular pneumonia is more gradual and there is, more- 
over, invariably a more or less extensive bronchitis, generally bilat- 
eral. The presence of two or more patches of consolidation points 
towards the lf>bular type, yet we must also remember the ])ossibility 
of ** pneumonia migrans," cases of genuine lobar pneumonia not un- 
common in children, where the seat of the disease appears to shift 
rapidly. The exact nature of such cases, it is difficult, at times im- 
possible, to det^Tmine clinically. The following case referred to me 
by Dr. R. H. Babcock, illustrates so well the difficulty of differenti- 
ating between these two types of pneumonia that it is given much 
in detail. 

April 27, 189-. 

A. B. — I^)y, years. 

F. 11. — Father has gastric trouble. 

Previous Hidory. — Cholera infantum at \) months. *' Sensitive 
stomach " ever since, with frequent epigastric pain afler meals. 
True measles one year ago. 



328 JBROXCHITIS, BRONCHO-PNEUMONIA, PNEUMONIA. 

Present Illness. — 5 days ago was attacked with rdtheln ; not at all 
sick. Now for two days has had considerable cough, without expecto-J 
ration. No pain anywhere ; no apparent constitutional disturbance. I 

Physical Examination. — Well developed, fairly well nourished,! 
face slightly flushed, respiration rapid but easy ; no dilatation of 
aire nasi, no expiratory grunt. Slight enlargement of cervical glands 
on both sides. 

Mouth. — Tongue thin white coat. Throat negative. 

Chest. — Lungs negative. Heart negative. 

Abdomen. — Negative. 

Pidse, Temperature, and Respiration. — ^Vide chart. 

Fig. 52. 



DAYS OF 
MONTH. 


27 


28 


29 


30 


1 


2 


3 


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5 


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7 


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DAYS OF 
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103 
101 
100 
99 

NORMAL 
TEMP. 

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120 

110 

100 

90 

80 

40 
35 
30 
25 


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Blood 



Red 6,104,000, Hb. Qo per cent. \ Two hours after break- 
White, 18,400 j fast. 
No Plasmodium detected. 
Diagnosis (provisional). — Central pneumonia (lobar ?) or (lobular ?) 
following so soon after the invasion of rotheln. 

April 28th. — Slight dulness and higher-pitched respiration just 
below left clavicle, as compared with right ditto. 



ACUTE LOBAR OR FIBRIXOCS ryEUMOXIA. 329 

Blood — AVhites, 22,400 (4 hours after breakfiist). 

Urine. — (24 hr.) 1,000 c.c, pale, aeid, 1,015, no albumen, no 
ir. Urea, 1.4 }>er cent., total urea, 14 g. Chlorides ()}, per cent., 

losphates 6^ per cent., Sulphates ^ 1 per cent. 

Diuf/nosis. — Lobar pneumonia, based on temperature and respira- 

m chart, physical signs in chest and diminished chlorides. 

April J^th. — Slight dulness and higher-pitched respiration at fcff 

ic posterior! I/. Slight dulness at lower angle of right scapula, over 
limited area. 

April oOth. — Signs in left front more marked ; scattering medium 
moist rales on both sides. Backs otherwise same. 

Mail 1st. — Sweating early this A. ^I. Chest as yesterday. Sputum 
frothy, whitish. Streptococci and tetragenococci. Xo pneumococci. 

Urine. — Chlorides 3^ per cent. 

MiUI ?(L — Left chest clearing up, top and base. At right base 
over limited area, between lower angle of scapula and axillary line is 
dulness, shifting with change in position of patient, and also distant and 
feebly bronchial respiration (9 A. M.). At 7 P. ^I. condition same, 
confirmed by Dr. Babcock, who saw the case in consultation. Aspi- 
ration, and about lo minims of sero-sancruinolent fluid withdrawn. 

Mai/ ^tli. — Right base, respiration more distinct. From this point 
on the signs in the chest gradually cleared up and patient made an 
uneventful recovery. 

The diagnosis in the above case on the first day was impossible, 
though the temperature and respiration rate suggested pneumonia, 
probably lobular on account of the antecedent attack of rotheln. The 
leucocytosis might have been due to digestion, only two hours after 
breakfast, or to either variety of pneumonia. The signs on the 
second day suggested a lobar pneumonia, coming to the surface be- 
neath the left clavicle, those on the next few days a case either of 
pneumonia '' migrans " or lobular with different patches of consolida- 
tion, eventually terminating with a pleuritic effusion, a condition 
more common in lobar than in lobular pneumonia. Bacteriological 
examination of the sputum showing absence of the pneumococci was 
against the lobar type. L^nfortunately but one examination of the 
sputum was made, and failure to find the pneumococcus once does 
not of course prove its absence. Tlie fall of the temperature by lysis, 
while more characteristic r»f loV)ular, is nevertheless ()l)S('rved not un- 
commonly in lol)ar ])neumnnia in children, in whom the course is so 
often atypical. 

The case illu-trate- the difficulty of differentiating hetwecn lliese 
two types of pneumonia. We must bear constantly in mind the 
irregularity of all processes in the young developing organism and 

' Pnrdv's method with percentage-tubes and centrifuge. See Chapter XXXVI., 



330 BRONCHITIS, BRONCHO-PNEUMONIA, PNEUMONIA. 

hence expect to see atypical cases of diseases, cases not presenting the 
clear-cut and well-defined course seen in adults. 

The symptoms of cerebro-spinal meningitis may at the onset be 
similar to those of lobar pneumonia. The temperature is lower in 
meningitis, the pulse is slower and often intermittent, the respiration 
slower and irregular. Lumbar puncture will be of value in arriving 
at a diagnosis, the fluid being cloudy and showing bacteriologically 
the presence of the characteristic diplococci. The subsequent course 
of the disease and careful exploration of the chest will determine the 
nature of the case. 

Cases of pneumonia beginning with vomiting and diarrhoea, 
especially in the summer, are sometimes overlooked and regarded as 
gastro-enteritis ; but at the onset the disturbance is too great for in- 
testinal trouble, and, later, examination of the chest will generally 
show characteristic signs. A marked degree of leucocytosis would 
point towards a pneumonia. 

If convalescence be tedious, the possibility of empyema must be 
borne in mind. This is unfortunately not at all an uncommon sequel 
of lobar pneumonia, and should be carefully watched for in all cases 
with a tardy and slow return to health.] 

Pneumonia is not a very fatal disease in children. Holt gives the 
mortality as 4 per cent.,^ but it is a little higher under three years of 
age. High temperature (106° F.) is not in itself of serious signifi- 
cance unless long continued. A sudden rise to 106° F., for instance, 
is less serious than a continued temperature of 104° or 105° F. In 
fact, the more acute the onset, and the more rapid the development 
of recognizable lobar pneumonia, the better, as a rule, the prognosis. 
Children attacked by well-marked lobar pneumonia are generally of 
robust type, and it is in such cases that resolution takes place in the 
most orderly manner. Apart from the occasional occurrence of very 
high temperature, the chief danger of uncomplicated pneumonia is 
cardiac failure, either during the height of the fever or at the moment 
of crisis. Pneumonia of the apex, even if it affect both sides, is of 
less unfavorable prognosis than in adults — in fact, recovery is the 
rule. In young children resolution is, as a rule, rapid, but after the 
age of eight or nine years convalescence is often tedious, and signs 
of local pleurisy and of imperfect expansion of the lung may remain 
for many weeks. The chief danger of acute lobar pneumonia in 
childhood is, indeed, its association with pleurisy. 

Pleuro-pneumonia is a more prolonged, more exhausting, and more 
fatal disease, and owing to the formation of extensive false mem- 
branes resolution is more tedious and less complete. The condition 
is best considered along with other forms of pleurisy. 

'In 1,482 cases there were 60 deaths. ''Diseases of Infancy and Childhood," 
London, 1897. 



ACUTE LOBAR OR FIBRINOUS PXEUMONIA. 331 

The treatment of acute piuniinonia must bo dirootcd to the relief 
of symptoms. Unless further ex}>erienee should ])rove that anti- 
pneumoeoecie serum, the use of wliieh is still iu the experimental 
stage, can be relied upon to cut the disease shin-t, no therapeutic 
means have any effect on the duration of the malady, which is lim- 
ited naturally. The child should be kept in bed in a room well ven- 
tilated and at an even temperature. It should receive small quan- 
tities of liquid food at short intervals (every two or three hours). 
The chest should be enveloped in a closely-fitting woolen garment, 
or in a cotton-wool jacket. Pain in the cliest is most promptly re- 
lieved by dry cupping ; fomentations, a linseed poultice, or a mus- 
tard poultice may bo used for the same purpose. Small doses of 
ipec:icuanha combined with sodium carbonate, repeated every hour 
or two hours for a day or a day and a half, mitigate the feeling of 
distress and still cough. All sedative remedies are better avoided, 
but occasionally it may be necessary to give a linctus containing 
codeine or antipyrin or phenacotin. [In view of the irregular course 
of pneumonia in children and hence the impossibility of foretelling 
the hour of crisis, great care should be observed in the use of these 
antipyretics, lest we get the combined depressing effect of the drug 
and crisis. A dangerous collapse from such treatment has come un- 
der the observation of the reviser. They should always be given 
combined with some cardiac stimulant : c. r/., caffein, coffee or brandy.] 
Great restlessness is best treated by sponging with cool water, or if 
the temperature bo very high, with cold or iced water. In extreme 
cases the ice pack to the chest has been used with success, but I have 
never seen occasion to resort to it. Commencing failure of the heart 
should be treated by digitalis ; at a later stage caffeine or camphor 
may be of use to tide the patient over the crisis or the hours pre- 
ce<ling its occurrence (see p. 79). In extreme cases of distension of 
the right side of the heart the withdrawal of a few (1 to 3) ounces 
of blood from the arm is certainly justifiable. After the crisis the 
patient should be put under the best hygienic conditions available, 
and should as soon as possiljle be removed from the room in which 
the height of the illness was passed. The room should be thor- 
oughly cleansed, and all woolen rugs, etc., as well as articles used by 
the patient during the illness, disinfected. Change of air should not, 
a« a rule, be advised until convalescence has lx?en completed. 



CHAPTER XXVII. 
PLEURISY. 

Sero-fibrinous Efiiision — Purulent Effusion — Symptoms of Pleurisy — Course — Phys- 
ical Signs — Loculated Empyema — Treatment. 

It is customary, in speaking of pleuritic inflammation with a 
recognizable quantity of fluid in the cavity, to draw a distinction 
between " pleurisy with effusion/^ by which is meant pleurisy with 
serous or sero-fibrinous effusion, and empyema, by which is meant 
pleurisy with purulent effusion. There is, however, no essential 
pathological difference, and no greater prognostic difference than there 
is between the early and the more fully developed stage of any other 
inflammatory process. This, at any rate, is true in children. If 
the statement requires any qualification, it is that the prognosis in 
serous effusion is rather less favorable, inasmuch as it is more often 
due to tuberculosis. The point is of importance, because it is often 
assumed, if a first puncture has yielded a serous fluid while a second 
yields a purulent, that the change was due to the puncture, whereas 
the effusions " are really purulent, and contain the microbic element 
of pus from the outset, although thev appear serous to the eye '^ 
(Koplik). 

Sero-fibrinous Effusion. — Inflammation of the pleura, with serous 
effusion only, is less common in children than in adults, and in young 
children than in those of more advanced age. It is rarely to be 
recognized in children under two years of age. Rilliet and Barthez, 
in 341 cases of primary pleurisy in children, found that 101 ooil | 
curred between two and five years. 111 between six and ten years,' 
and 129 between eleven and fourteen years. The inflammation of 
the pleura may be primary or secondary. 

Exposure to cold is frequently a determining cause of pleurisy, 
and injuries to the chest may also produce inflammation of the pleura 
with effusion. Pleurisy may be rheumatic, and in some cases appears 
to be secondary to pericarditis. It may occur also as a complication 
of typhoid fever, scarlatina, or measles. The most important causes 
of pleurisy are tuberculosis and pneumonia. Inoculation experiments, , 
prove that 40 per cent, of the pleurisies apparently due to exposurA I 
to cold are really tuberculous, and clinical observation shows that a 
very large proportion of patients who suffer from pleurisy with 

332 



PURULEST EFFUSIOX. 333 

serous effusion eventually develop tuberculosis of the lungs. The 
relation of pleurisy to pneumonia is very intimate. In children it 
is probably the rule to have some involvement of the lung ; many 
writers, indeed, follow the example of Andral, and speak of all non- 
tuberculous inflammations of the pleura as jt/euro-pncu mania — a 
course which is at least extremely convenient, since the diagnosis 
between commencing pleurisy with cttiision and superticial pneumonia 
accompanied by pleurisy is often difficult and sometimes impossible. 
Inflammation of the substance of the lung, whatever its extent, is, 
if it reach the surface, probably always accompanied by some pleurisy. 
In fact it is not very uncommon for an attack of acute pneumonia in 
the child to be accompanied by extensive involvement of the pleura, 
and to be followed by considerable effusion. In broncho-pneumonia 
the pleurisy is generally local, and the same is true of infarct ; but 
in either case the ]ileurisy may become general. 

Purulent Efiiision [EmiJi/cma). — Pleurisy with purulent effusion is 
a common disease in children of all ages, but is particularly frequent 
between the ages of two and six. The effusion may at first be serous, 
or it may have the characters of pus from the earliest stage. As 
already said, the difference is one of degree and not of kind. The 
altemtion in the appearance of the fluid is due to an increase in the 
number of cells — an increase progressive from the first, and depend- 
ent upon the character of the inflammatory process. 

In the majority of cases of purulent pleurisy in children the pus 
is thick and viscous — the custard-like pus which used to be called 
" laudable." Pus of this kind is associated with the presence of the 
pneumococcus, which appears to be the determining infective agent 
in 72 per cent, of all purulent pleurisies in children. The purulent 
pleurisy due to the pneumococcus may be either secondary to pneu- 
monia or pleuro-pneumonia, or primary, although in most cases in 
which it appears to be primary it is probably either secondary to or 
accompanied by undiscovered pneumonia or broncho-pneumonia. 
To the jiurulent pleurisy which occurs in associati(>n with pneumonia 
Gerhardt, who had recognized the association before bacteriology ex- 
plained its nature, has applied the term meta-pneumonic — a convenient 
term, since the cases l)elong to a distinct clinical group which call for 
a special line of treatment, and in which the ])rognosis is l)etter than 
in other forms of pleurisy. The pneumonia may be primary, or 
may be secondary to scarlatina, measles, or typhoid fever. The 
pleuritic complication may be discoverable during the pneumonia, 
soon after the crisis, or some weeks or even a month later. The 
symptoms of onset may Ix' well marked or latent, and the j)leuritic 
pnx^ss may terminate in absorption, by ojx^ning into a bronchus, by 
becoming encysted, or by ojK*ning externally, |H'rhaps after tracking 
fer down, so as to point in the lumbar region or groin. 



334 PLEURISY. 

In a minority of cases in children purulent pleurisy is associated 
with tlu^ presence of one of the ordinary pyogenic cocci, and in a con- 
siderable proportion of the cases the primary lesion is tuberculous. 
The disease can be shown to be secondary to some contiguous local 
centre of inflammation in the majority of cases — broncho-pneumonia, 
suppurative angina, perhaps pericarditis or peritonitis. In a few it 
occurs in the course of scarlatina, diphtheria, erysipelas, or otitis, and 
in these cases the infective agent is probably carried by the blood. 
In a few cases only can no primary purulent focus be discovered. 
Puncture at an early stage may withdraw a clear fluid, which, how- 
ever, gives a slight precipitate on standing. At a later stage, and 
in some cases at the earliest stage at which exploratory puncture ap- 
pears justifiable, the fluid is purulent. It is a thinnish, yellow pus, 
w^hich quickly lets fall a fine powdery precipitate. 

The symptoms of pleurisy vary very much in intensity. Small 
patches of localized pleurisy associated with broncho-pneumonia are 
difficult to recognize, since the physical signs do not present any 
marked peculiarities, and complaint of pain in children is often very 
indefinite. The degree of pain appears, indeed, to be very dificrent 
in different cases. In children of six or seven to twelve years 
old, attacks of acute dry pleurisy, attended by much pain, are not un- 
common. Friction may be absent, unless the child takes a deep breath. 
Deep inspiration brings out a dry, creaking, or fine crepitant rale, which 
may be heard only at the end of inspiration. Expansion on the af- 
fected side is diminished owing apparently to the pain which a full 
inspiration causes. In a well-marked case the child sits with the 
shoulder on the affected side lower, nursing the elbow against the 
chest. Owing to the deficient expansion the breath-sounds on the 
affected side are feeble, and it may be difficult to induce the child to 
take an inspiration deep enough to elicit friction. The percussion 
note is not altered. The general symptoms are not very distinct ; 
the temperature may be very little above the normal, but it may 
touch 100° or 101°, the pulse is quickened a little, and there is 
some malaise and perhaps headache and loss of appetite. In such 
a case the symptoms described may all subside in a few days or they 
may be succeeded by signs of effusion. The effusion leads to a 
diminution or disappearance of pain, and a false appearance of gen- 
eral improvement. It is, therefore, unwise to trust to the patient's 
sensations, and very desirable to make a careful physical examina- 
tion before accepting the patient's assurance that he is cured. Some 
of these cases are probably rheumatic. 

The onset of the severer form of pleurisy may be acute or insidious. 
If acute, it resembles the onset of pneumonia, which, indeed, is gen- 
erally co-existent. The disease begins with a rigor, or shivering and 
a sensation of chilliness in older children, with stupor or convulsions 



PLE URO-PNE UMOMA . 335 

in younger. The temperature rises to 103° or even 105°, the pulse 
to 140 or even 180, though when those extremes are reaehed there 
is probably a good deal of pneumonia also ; respiration is hurried and 
shallow, and on the atleeted side expansion is diminished. The ex- 
pression of the face is anxious or peevish, cough if present is short 
or painful, so that it is often followed by crying. Children of five 
or six years, or even younger, may point to an area where pain is 
felt. This area will be a little tender, and on deep inspiration fric- 
tion or a small crepitant rale may be heard. If the onset be insidi- 
OHS the child is brought under treatment because it is pale and lan- 
guid, has a slight dry cough, and complains of pain in the side or 
alxlomen (generally the epigastrium). The pulse is a little hurried, 
a.«s is respiration, and the child is found to have some irregular fever. 
"When the disease has become esfablishedy and there is more or less 
effusion, there is marked pallor of countenance, perhaps some cyano- 
sis, though this is less than in pneumonia, dyspncpa, and some pain 
or discomfort in the chest. The general condition of the patient de- 
teriorates quickly, and there is rapid emaciation. The temperature 
is high, with remissions which generally occur in the morning but 
seldom reach normal. Pain in the side is generally less than at an 
earlier stage, but tenderness may be more pronounced. AMien well 
marked it probably indicates that the fluid is becoming more dis- 
tinctly purulent. 

In pleuro-pneumonia — when, that is to say, there is extensive 
infection of the lung and pleura by the pneumococcus — the signs of 
consolidation will be marked early, and an imperfect crisis will occur 
on the eighth, ninth, or tenth day, or even later. Defervescence is 
not complete, and fever remains, of hectic type but with remissions 
at irregular intervals. 

The termination of an attack of pleurisy may be in resolution with- 
out effusion, but with the formation, probably, of adhesions, which 
may \ye the source of after pain. If fluid is effused, it may become 
pnndent ; this is in children by far the most common termination. 
In many cases the surface of the lung is from an early stage covered 
with false membrane (Fig. 53), and eventually a condition may be 
produced to which the term thirkrnefJ pleura is commonly applied — 
a condition in which the false membranes persist. They become 
^edematous, and there is also perhaps some free fluid, generally ])uru- 
lent. The membranes in time become more or less organized, and 
there is accompanying fibroid degeneration of the pleura and subjacent 
lung. 

The recognition of the purulent nature of a collection of fluid in 
the chest is often exceedingly difficult until an ex])loratory puncture 
with a hypodermic syringe has been made. The more acute the his- 
tory of the case, the more likely is it that the fluid is purulent. That 



336 PLEURISY. 

the attack lias come on during scarlatina, measles, or some other 
exanthem is evidence in favor of fluid. Tenderness, oedema, or 
localized redness also point to pus, the last-named sign perhaps to 
approaching pointing of the pus at the surface. The duration of the 
case must also be taken into consideration ; if the history extends to 
three or four weeks, and there are signs which point distinctly to 
fluid rather than to thickened pleura, the diagnosis of pus may be 
made with considerable confidence, especially if the temperature is of 
the hectic type, and the patient losing weight rapidly. 

The physical signs of fluid in the pleura are the same whatever its 
nature, but they vary according to its amount and situation. When 
the quantity of fluid is large there ought to be no difficulty in mak- 
ing a diagnosis, although mistakes are often made. It should never 
be forgotten that a case which begins as pneumonia may terminate 

Fig. 53. 




Section of the border of a lung affected by acute pleuro-pneumonia, showing the thick false 
membrane. X 5. (From photomicrograph by Mr, F. Fowke.) 

as one of eflusion into the pleura. On inspecting a chest in which a 
considerable quantity of fluid is effused into one or other pleural 
cavity, it is seen that there is less movement on the affected side. 
When the quantity is large there may be some bulging of the chest 
as a whole, though the intercostal spaces may not be full, may indeed 
even recede in inspiration. There is loss of vocal resonance, which, 
however, cannot be perceived unless the child cry, which it is often 
indisposed to do, owing probably to the pain thereby caused. Alter- 
ation in vocal fremitus cannot, for the same reason, be depended on to 
give much information. Palpation may detect some fulness of the 
intercostal spaces, some defective expansion not observed by the eye, 
but the most important information it can afford is as to displacement 
of the heart. If the effusion is on the right side, the heart may be 
much displaced to the left, so that the apex beats outside the nipple, 



LOCULATED EMPYEMA. 337 

or at the axillary margin. AVhoii the eifusion is on the left side the 
displacement of the heart is not so easily perceived nnless the qnan- 
tity of linid be large. In a case in ^vhich old plenrisy and fibroid 
phthisis can be exclnded, well-marked displacement of the heart is 
almost conclnsive evidence of flnid in the pleura, but failure to de- 
tect displacement does not negative a diagnosis of eifusion rendered 
probable by other signs, since the quantity of fluid may be too small, 
or adhesions may retain the heart near its normal position. More- 
over, the heart-beat may be difiicult to localize or to perceive at all 
by the hand, and then reliance must be placed on an estimate of the 
point at which the heart-sounds are best heard. The percussion note 
over fluid is quite dull, and a peculiar sensation is communicated to 
the finger in contact with the chest, which is commonly described as 
** wooden." This peculiar woodenness is characteristic, and the best 
single sign of fluid ; but if the percussion be too heavy it may not 
be jx^rceived, and a resonant note may be obtained in the elastic 
chests of young children, owing apparently to the resonance of the 
lung of the opposite side. A light, short percussion stroke is there- 
fore necessary. Immediately above the upper level of the fluid a 
tympanitic note may be obtained, probably produced by relaxed lung, 
but this will not be observed in the later stages of the case, when 
the lung is completely collapsed in this area. It will seldom be 
possible to make out that the dulness shifts with change of attitude ; 
indeed, the constancy of the area of dulness in all attitudes and often 
for many days together is remarkable. The signs of dulness will 
probably first be detected at the back, and the dulness will reach 
higher in the vertebral groove near the spine ; later, the vertical 
depth of dulness is often greatest in the axilla. Very little infor- 
mation can be obtained from auscultation, especially in the later 
stages of fluid effusion into the pleura ; the breath-sounds over the 
dull area may be bronchial, or even tubular, in which case they ap- 
pear to confirm a diagnosis of pneumonia, or they may be feeble or 
al^ent, as in the earliest stage. When the quantity of fluid is large 
the breath-sounds, whatever their tone, are, as a rule, feeble and dis- 
tant. The percussion note over thickened pleura is dull, higli- 
pitched. but not wooden. 

Loculated Empyema. — An irajwrtant class of cases remain for 
consideration — those in which the fluid is from an early period 
limited by adhesions. The fluid which is nearly always purulent, 
may l)e localized at any part of the surface of the lung — back, front, 
axilla, or apex ; or it may gather l)etween the lobes — the so-called 
cystic empyema; or it may accumulate between tlie base of the lung 
and the diaphragm — diaphragmatic pleurisy. On the surface the 
symptoms and signs are those of ordinary pleurisy, exce])t that they 
iDvolve a limited area, and are therefore particularly liable to be 
22 



338 PLEURISY. 

mistaken for pneumonia or broncho-pneumonia. A certain diagnosis 
is not to bo made without exploratory puncture, unless the quantity 
of iiuid be so large as, practically, to take the case out of the cate- 
gory of loculated empyema, which we are now considering. Inter- 
lobar pleurisy (cystic empyema) can seldom be diagnosed with 
certainty. The diagnosis of diaphragmatic pleurisy is exceedingly 
difficult and uncertain. The symptoms are very obscure. Pain is 
referred to the upper part of the abdomen ; on the right side there 
may be notable depression of liver, but as there is dulness at the 
base back and front due to the fluid, it is not easy to say that en- 
largement of the liver may not be the cause of its lower border being 
unduly low in the abdomen. As a matter of fact, diaphragmatic 
pleurisy is seen more often in the post-mortem room than diagnosed 
during life, except in those rare cases in which the pus tracks down 
and points in the loin or groin. 

The treatment of acute pleurisy must be symptomatic. A dose of 
calomel given at the onset is beneficial in most cases. In the early 
stage, when there is violent stitch in the side, sodium salicylate gives 
relief sufficiently often to^render it worthy of trial, the more so that 
in some cases it appears to check the effiision of fluid also, and so to 
bring the attack to an end. When this drug fails the pain may be 
relieved by hot fomentations, or by the local cold pack, or, if neces- 
sary, by the ice poultice. Iodine and other counter-irritants seldom 
succeed, and are not desirable applications in young children. "When 
the amount of fluid effused becomes considerable, the pain is greatly 
diminished ; if the temperature subside simultaneously, and the 
breathing be not greatly embarrassed, no active treatment is required. 
The patient should be kept at rest but not confined to the house, 
the bowels should be caused to act freely every day, and light food 
should be given. If the quantity of fluid effused either at the onset 
or later be sufficiently large to embarrass respiration and to produce; 
perhaps, some cyanosis or anasarca, there should be no hesitation in 
drawing off the fluid w^ith antiseptic precautions. There remain a 
class of intermediate cases in w4iich it is often very difficult to decide 
whether aspiration is advisable. The operation itself, if the fluid be 
withdrawn gradually, and if antiseptic precautions be observed, is 
harmless, and it is certainly inadvisable to postpone it too long; the 
withdrawal of part of the fluid is sometimes followed by absorption 
of the remainder. If exploratory puncture shows that the fluid is 
purulent, incision followed by drainage is usually necessary, and 
should not be long deferred. 

[Immediate evacuation of the fluid is imperative as soon as a 
diagnosis of empyema is made. Delay is dangerous, and the earlier 
the operation, the better the results. The pus should be evacuated 
by either aspiration, simple incision, or resection of a rib. As to 



LOCULATED EMPYEMA. 339 

which of these methods should be pursued must depend on the eir- 
cumstances of the individual ease. The general eondition of the 
patient and the type oi pleurisy present nuist be taken into eonsider- 
atiou. If the child be in a weak caeheetie eondition, as so often 
happens in hospital eases coming in late in the disease, simple in- 
cision is to be preferred. Irater, at\er the eliild's general eondition 
has improved by tonic treatment, it may be necessary to resect a 
rib. In uncomplicated pneumococcic empyema, simple incision or 
even aspiration is generally sufficient, but in cases of streptococcic 
empyema, a free opening with resection of a rib is best. A bacterio- 
logical examination oi the fluid obtained by exploratory puncture is 
thus, it will be seen, of practical importance in deciding upon the 
choice of operation.] 



CHAPTER XXVIII. 
CHRONIC AFFECTIONS OF THE BRONCHI. 

Chronic Bronchitis and Emphysema — Bronchiectasis — Asthma — '^ Hay Fever." 

Chronic Bronchitis. — Children who have had one attack of acute 
bronchitis are not only predisposed to fresh attacks but in many 
cases suffer in the intervals from chronic bronchial catarrh. After 
measles and whooping-cough this tendency is particularly marked. 
The subjects are generally ansemic and ill nourished, the skin puffy, 
the muscular system flabby. If under three years old, they are 
usually rickety, and often suffer from gastro-intestinal catarrh. 
Cough is troublesome, especially at night, often paroxysmal. The 
chest is resonant on percussion, and the note often high-pitched over 
the upper parts of the lungs in front. A few scattered sibili may be 
heard, or coarse rhonchi, in the interscapular region. A tenacious 
clear mucus is expectorated, if the child be old enough, in small 
quantities. On exposure to cold,, or any slight disturbance of the 
general health, such as may be produced by dentition, an aggrava- 
tion of all the symptoms is very apt to occur, and numerous sibili 
and rhonchi of various degrees of coarseness may then be heard. 
The expectoration becomes more abundant and fluid. Later it is 
muco-purulent and the cough loose. The mucous membrane of the 
bronchi is hypersemic aud thickened, and there is usually some 
emphysema of the apices and anterior borders of the lungs. As a 
rule, except during the exacerbations, respiration is free, but in 
children over six or seven years old attacks of dyspnoea of the nature 
of spasmodic asthma may occur. 

Typical examples of ch'onic emphysema are not very uncommon in 
children above the age of nine or ten years. The patients, usually 
boys, have a characteristic appearance. They are clumsy and thickset 
in figure, slow in movement, and indisposed to exertion ; the shoulders 
are rounded, and they stand Avith the head bowed and the arms 
hanging loosely ; the face is broad and congested, the chest barrel- 
shaped, the bones of the limbs are large, the fingers clubbed, the 
skin dry and harsh ; the chest is sub-tympanitic on percussion, the 
breath-sounds are weak generally but rustling at the apices ; the 
appetite is poor, the bowels costive. Slight exertion causes dyspnoea, 
which is often accompanied by some rhonchus, and followed by 

340 



CHROSIC BROXCHITIS. 341 

paroxysmal cough, ending in the expectoration of frothy mucus. 
Attacks of an asthmatic character may occur without obvious cause. 
The patients are extremely liable to sutler from bronchitis. The 
dyspnoea is then much increased, they are unable to lie down, and 
the concjestion of the face becomes extreme. Fits of couo^hins: are 

~ or? 

severe, and end often in vomiting. At the beginning of one of these 
attacks, loud sonorous and sibihint rhonchi generally obscure all 
other sounds, and expectoration is scanty and tenacious. After a 
day or two small rhonchi and loose mucous rales are heard in all 
parts of the chest. The temjx^rature is a little raised. During the 
winter many such attacks occur, and the patient is never really free 
from bix^nehitis except during mild, warm weather. AVith each 
winter his condition grows worse. He becomes much emaciated, the 
right side of the heart dilates, and the dyspnoea on slight exertion 
confines him to a sedentary life. Chronic gastro-intestinal catarrh is 
a common complication. 

The history of the case and the physical signs usually render the 
diagnosis of chronic bronchitis easy, but it should be remembered that 
a large proportion of the cases to which this term is j^opularly ap- 
plieil are really examples of gmnular pharyngitis or adenoid disease 
of the naso-pharynx (7. v.). The diagnosis of spasmodic asthma 
should only \^e made after bronchial catarrh, and enlargement of the 
tracheo-bronchial glands have been excluded. This will not often 
be the case, though in many cases of chronic bronchitis a spasmodic 
element in the production of the attacks of dyspnoea may be recog- 
nized. 

The prognosis in simple chronic bronchitis depends far more upon 
the general state of the patient's healtli than on the local condition. 
Chronic broncliitis in a rickety child is always a rather serious con- 
dition, owing to the fact that it favors collapse of lung and the oc- 
currence of acute bronchitis and broncho-pneumonia. In older chil- 
dren the degree of emphysema is the most important element in 
prognosis. When this is well marked, when there is dilatation of 
the right side of the heart, and cyanosis even though slight, there is 
little prospect of recovery, and few such patients reach adult age. 
Each winter sees an aggravation of their condition, and they suc- 
cumb to intercurrent acute bronchitis, with which, owing to the em- 
barrrtssment of the heart already existing, they are little able to cope. 

In the treatment of chronic bronchitis in young children the most 
important jx^ints are to prevent fresh attacks of acute or subacute 
bronchitis, and to improve the general nutrition. Cod-liver oil is 
verA* valuable in these cases, especially when, as commonly happens, 
the rhild is rickety. The r>rdinary expectorants are not of much 
use, but Dr. Eustace Smith recommends liquid tar (one drop two or 
three times a day on sugar, or in older children in capsule or pill). 



342 CHRONIC AFFECTIONS OF THE BRONCHI 

Counter-irritants to the chest are useful. Turpentine liniment well 
rubbed in is the best, since some turpentine is absorbed and has a 
beneficial action. Iodine liniment is also a good application, dif- 
ferent areas, each about three inches in diameter, being painted daily. 
The child should be clothed in woolen garments next the skin, and 
if, owing to wet and damp weather, it be necessary to keep it in- 
doors, gentle gymnastic exercises are advantageous. When possible, 
it should pass the winter in a warm and sunny climate, so that it 
may be able to get out of doors daily. In marked cases of emphy- 
sema in older children treatment by drugs has little effect. When 
cough is troublesome stimulant expectorants and turpentine inhala- 
tions by day, and turpentine liniment rubbed into the chest at night, 
are useful. Gentle gymnastic exercises on the Schott system are of 
use if there be cardiac dilatation. Winter in a cold damp climate 
entails much confinement to the house, and attacks of bronchitis are 
almost impossible to be avoided. A mild, sunny, and rather moist 
climate suits these patients best. 

Bronchiectasis. — The frequency with which dilatation of the 
bronchi occurs in children is a point upon which there is room for 
much difference of opinion. In a large proportion of cases it is as- 
sociated sooner or later with tuberculosis. It cannot be produced by 
mechanical means alone, as, for instance, by coughing. Some lesion 
weakening the bronchial wall must precede the dilatation. 

In children the most important causes are broncho-pneumonia, 
especially that secondary to measles, whooping-cough, influenza, and 
typhoid fever ; pleurisy and pleuro-pneumonia ; and, more rarely, 
primary chronic tuberculosis of the lungs. Among the less common 
causes may be mentioned chronic bronchitis, atelectasis, foreign 
bodies in the bronchi, constriction of a bronchus, and pulmonary 
syphilis. Any debilitating general condition, such as malnutrition, 
overcrowding, rickets, or chronic enteritis, tends to render permanent 
the dilatation which accompanies broncho-pneumonia. The mode 
in which these many causes bring about dilatation is different. In 
broncho-pneumonia the small bronchi in the affected areas share in 
the inflammation. Their walls are weakened, and, the surrounding 
alveolar tissue being either consolidated or collapsed, the positive 
pressure in expiration or during cough must act upon the bronchi 
and upon the adjacent unaffected lung tissue, producing in the one 
case bronchiectasis and in the other alveolar emphysema. Partial 
obstruction of a bronchus impeding complete expiration will favor 
the dilatation of its distal part. The dilatation thus produced is 
doubtless, as a rule, transient, and a gradual restitution accompanies 
the recovery of the lung. Godlee ^ has called attention recently to 
the advisability in cases of unilateral bronchiectasis, in children es- 
iKoy. Med. Chi. Soc, March 24, 1896. 



BEOKCHIECTASLS. 343 

pecially, of making careful inquiries as to the possibility o^ ci foreig)) 
bodif having been inhaled. In some eases such an accident may 
cause acute bronchiectasis and gangrene of the lung, but in others 
the inconvenience produced at the time is so slight that the accident 
is forgotten, or not connected with the subsequent pulmonary dis- 
ease. If the foreign body be expelled, (1) complete recovery may 
take place, (2) the signs of bronchiectasis may persist, or (3) the 
piitient may succumb to tubercle engrafted on the primary bronchial 
disease. 

To pi\>duce permanent bronchiectasis it is necessary that fibroid 
changes should take phice in the lung. Thus if the broncho-})neu- 
monia be tuberculous, or become so, the sclerosis which attends the 
retix>gression of the tuberculous process may render the bronchial 
dilatation permanent and in time increase it. Pleuro-pneumonia and 
pleurisy leading to extensive adhesions or to long-standing collapse 
of lung, with subsequent imperfect expansion of the alveolar struc- 
ture, as in empyema, are always attended by dilatation of bronchi. 
Under such circumstances, when the chest wall and the thoracic and 
abdominal organs have l)een displaced as much as possible, the con- 
tracting forces tend to produce dilatation of the bronchi. The 
bronchi most often dilated are those of medium and small size, and 
the changes are limited usually to one lung, and during childhood to 
the l)ase. AVhen established, the bronchiectasis is usually fusiform, 
but it may be cylindrical or form a lateral dilatation. The bronchus 
on the proximal side of the dilatation may be of normal calibre or 
contracted ; beyond it may be obliterated. The pulmonary tissue 
surrounding the dilatation is sclerosed, and the scattered areas of 
emphysema in the parts of the lung which still remain pervious. 
Occasionally a single bronchus presents several dilatations. The 
lining of the dilatations is formed by a degenerate mucous membrane, 
which in chronic cases may have a granular surface. In association 
with decomposition of the retained secretions, superficial gangrene 
of the mucous membrane may occur. The communication between 
the proximal end of the bronchus and the dilatation may become 
closed, and a caseous and calcareous degeneration then ensues. The 
dilatation of bronchi secondary to empyema is commonly extensive, 
several or many l)ronchi being affected in their whole extent. 

The physical signs vary according to the extent and degree of the 
dilatation, ^^'hen broncho-pneumonia is complicated by considerable 
bronchiectasis there will be found at the posterior bases, but more 
marke<l usually on one side, and generally within an area of deficient 
resonance, increased vocal resonance, cavernous or even amphoric 
respiration, and coarse metallic or loose bubbling rales. In chronic 
bronchiectasis with pulmonary sclerosis the j)hysical signs vary ac- 
cording to the nature of the condition ujxjn which the dilatation de- 



344 CHRONIC AFFECTIONS OF THE BRONCHI. 



i 



pends. If on chronic bronchitis, which leads to dilatation of the 
large bronchi, there will be loud bronchial and even cavernous 
breathing in the interscapular region and below ; if on old pleurisy, 
there will be the deformities produced by that condition, but the 
sounds produced within the dilated tubes Avill depend on whether 
they be full or empty. ^^ If the dilated tubes are full of muco-pus, 
the breath-sound is weak and bronchial, with little rhonchus ; and 
the resonance of the voice when the child speaks is faint or sup- 
pressed. If the air-passages are comparatively empty, the respira- 
tion is loud and blowing, often intensely cavernous, or even amphoric, 
with metallic echo ; and large, crisp, metallic bubbles, with dry 
creaking sounds, are heard with both inspiration and expiration.^' ^ 

The symptoms produced by bronchiectasis are governed to a great 
extent by the condition to which it is secondary. When extensive, 
the characteristic symptom is the sudden onset, generally in the morn- 
ing, of a severe paroxysm of coughing, producing much distress and 
congestion of the face and ending in the expectoration, often accom- 
panied by vomiting, of a large quantity of sputum, of a grey or grey- 
brown color, as a rule fluid, and often, owing to retention, very offen- 
sive. On standing, it separates into a granular puriform layer below 
and a mucous layer above, upon which float muco-purulent shreds 
and a brownish froth. The respiration is a little hurried. In time 
considerable dilatation and hypertrophy of the heart may be pro- 
duced, with some constant cyanosis of the face and clubbing of the 
finger-tips. Bronchiectasis may cause little or no fever ; but in time, 
if the dilatations are numerous and large, the patient begins to suffer 
from hectic fever, and becomes much emaciated. In the majority of 
cases this unfavorable change is due to intercurrent tuberculosis ; 
but it is aggravated, and in some cases produced, by the absorption 
of toxic bodies from the retained secretions. On the other hand, 
bronchiectasis may persist for many years, from childhood to age, 
without preventing the sufferer from following an active life, and 
recovery, though rare, is not impossible, if the dilatation be not too 
considerable. On the whole, therefore, the prognosis depends rather 
upon the nature of the complications than upon the mere discovery 
of bronchial dilatation. 

The diagnosis is often a matter of great difliculty, and is commonly 
impossible unless the patient can be watched for some time. The 
special characters of bronchial dilatations are that they are usually 
situated at the bases, and that they are stationary — that is to say, 
the physical signs they produce show no tendency to spread over a 
larger area, but rather the reverse. Confirmatory evidence that the 
process is not tuberculous is afforded by the absence of fever, and of 
tubercle bacilli from the sputum. 

^ Eustace Smith, "Disease in Children," p. 502. 



■ 



ASTHMA. 345 

Treatment directed to the relief of the symptoms produced by 
bronchiectasis is sekloni called for, except when the expectoration is 
foul and copious, the two conditions going usually together. Of all 
internal remedies turpentine is the best. It diminishes the amount 
of secretion and checks the tendency towards decomposition. The 
oil of turpentine may be given to the extent of lUx-xx daily to a 
child of 10 or 12 in three doses, and the air of the room may be 
charged with it. Various substitutes have been suggested, such as 
pure terebene, and terpine, and the oils of fir and of eucalyptus for 
diffusion through the air of the room. Inhalations of creasote, car- 
bolic acid, etc., are not of much use, but as an internal remedy 
creasote is often useful. Tar administered in capsules, pill, or the 
syrup of tar (U. S. Ph.) often gives relief. The cough should not 
be checked unless it interferes with sleep. Frequently the patient is 
aware that a particular attitude — generally lying down on the side on 
which he does not habitually sleep — will excite the cough ; and when 
this is the case, he should be advised to assume this position twice 
or thrice in the twenty-four hours so that the dilated bronchi may be 
emptied. Intratracheal injections (menthol 10 per cent, and guaiacol 2 
|)er cent, in olive oil) have been recommended for adults, and incision 
of the cavitv followed bv drainajre has triven ffood results in some cases. 
The general health should be maintained, and a mild winter climate is 
desirable, so that the patient may be able to spend much time out of 
d<x)r^. A dry is better than a moist climate, except in very extreme cases. 

Asthma. — " Bronchial asthma is a neurotic affection, characterized 
by hypenemia and turgescence of the mucosa of the smaller bronchial 
tubes and a peculiar exudate of mucin '' (Osier). Accepting this 
definition, true asthma must be held to be uncommon in childhood, 
but children over four and five years of age, who are the subjects of 
chronic bronchitis and emphysema, or adenoid vegetations and ob- 
struction of the nose, are very liable to asthmatic attacks, which may 
be brought on by sudden exposure to cold, by air laden with dust, or 
by dyspeptic di.«-turbances. 

During the attacks the breathing becomes labored, expiration pro- 
longed, and the chest full of sibili. The face is flushed, and expresses 
much distress. After a few hours the difficulty in respiration passes 
off, but the child is exhausted, and dreads a recurrence. At the end 
of the attack expectoration, previously su])pressed, becomes free ; it 
is accompanied by cough, and often contains small masses of thick 
tenacious mucus. In its more marked forms bronchial asthma is 
probably in most cases due to a chronir* relapsing bronchial catarrh 
characterized by the formatirm of a plastic exudation. It is this ex- 
udation which yields the tenacious masses above mentioned. In rare 
instances the masses may have a distinct dendriform shape, apparently 
ca.sts of the smaller bronchi. 



346 CHRONIC AFFECTIONS OF THE BRONCHI 

Children are liable also to hay fever. The attack begins with itcl 
ing of the nose and coryza. Usnally some bronchial catarrh ensuesj 
and the child loses appetite and becomes restless and irritable. Only 
in rare cases are distinct asthmatic attacks observed. 

In the treatment of children liable to asthmatic attacks attention 
should first be directed to the relief of bronchial catarrh or naso-pha- 
ryngeal disease, if these be present, and to the prevention of dyspep- 
sia by careful dieting. AVhen bronchial catarrh is present, the addi- 
tion of potassium iodide to an expectorant mixture may ward off the 
attacks. During the attack nitre paper may be burned in the room, 
or in very severe cases four or five drops of chloroform may be in- 
haled from a handkerchief. The best climate for patients subject to 
asthma, if not also suffering from emphysema, is that of a high and 
dry health resort, such as the Alps in summer, though hay and dust 
should be avoided. In the treatment of hay fever the use of anti- 
septic lotions (boric acid, perchloride of mercury 1 in 4,000) for the 
eyes and nose at the onset may arrest the attack. A bland ointment 
(such as borax lanoline) should be introduced into the nose. As a 
rule, however, such patients do not do well in the country in the 
spring and early summer, and should, if possible, live in a town or 
at the seaside. 



1 



CHAPTER XXIX. 
PERITONITIS. 

Acuie Peritonitis — Chronic Peritonitis — Appendicular Peritonitis ; Local Adhesive 
Peritonitis : Perityphlitic Abscess ; Acute General Peritonitis. 

If cases due to tuberculosis be excepted, peritonitis, whether acute 
or chronic, is a rare affection in infiints and chikh'cn. 

Acute peritonitis occurs sometimes in new-born infants as a 
consequence of septic infection. In older children it is a consequence 
in tlie majority of cases of inflammatory disease of the vermiform 
appendix. Among the remaining cases to be enumerated the most 
important is injury ; others are intussusception and foreign bodies or 
fjecal masses impacted in the intestine. It has been observed also 
as a complication of certain infectious diseases — small-pox, diphtheria, 
typhoid fever, and especially scarlet fever. The inflammation is as- 
sociated with the presence of certain microbes, among which may be 
mentione<l as the most common the bacillus coli communis, but strep- 
tococci and the diplococcus pneumoniae have also been found. 

The morbid appearances in the peritoneum are vascular injection, 
ecchymoses, and fibrinous exudation. The amount of fluid effused 
is usually scanty, l)ut may be very considerable. It seems to be 
more liable to Ix^come purulent in children than in adults. 

The symptoms are the same as those in the adult. The patient 
lies on the back with the knees drawn up, and dreads every move- 
ment which aggravates the severe abdominal pain from which he 
suffers. The belly quickly becomes distended, tense, and tympanitic, 
the respiration thoracic. Dulness on percussion may be discoverable 
in the flanks or iliac fossa, but this is the exception. Thirst is in- 
tense, but everything which is swallowed is rejected almost immedi- 
ately. The tongue is small, dry, and red. Constipation is almost 
invariable, and retention of urine not unconnnon, owing in ])oth cases 
to paralysis caused by the peritonitis. Fever is high, the skin hot 
and dry, the pulse rapid and hard, and after a short time thready. 
Death occurs in a large majority of all cases within four to eight 
days, but if the patient survive the intense nervous depression and 
general exhaustion accomj)anying the onset c)f the disease, immediate 
recovery is possible. More often in children suppuration occurs ; 
the acute symptoms subside to some degree, and then, as a rule dur- 

347 



348 PERITONITIS. 

ing the second week, the fever returns, accompanied often by a rigor ; 
the belly increases in size ; dulness and perhaps fluctuation becomes 
perceptible ; the navel becomes everted, red and tender, and finally 
gives way, aifording exit to a large quantity of purulent fluid. In 
other cases the suppuration is more limited, and makes its way 
towards the surface at any point, but most often in the hypogastric 
region ; the skin becomes red, and fluctuation may be perceived. 
Spontaneous rupture through the umbilicus, or evacuation of a local- 
ized collection of pus by incision, appears generally to be followed 
by recovery. 

The diagnosis as to the cause of the peritonitis, upon which the 
prognosis must in a large measure depend, is generally very doubtful, 
except when the peritonitis is due to inflammation of the appendix. 
It is seldom possible to exclude tuberculosis, which is by far the 
most common cause of acute peritonitis in children. 

The treatment of acute peritonitis can be palliative only, unless it 
be considered prudent to follow the method recommended by some 
abdominal surgeons of giving saline purgatives when the onset of 
peritonitis is apprehended after laparotomy. Under ordinary cir- 
cumstances, cases will hardly be seen early enough to render such a 
course of treatment otherwise than certainly disastrous, and it is con- 
traindicated in perityphlitis, which is the commonest cause of acute 
peritonitis in childhood. Hot or iced applications to the belly, if 
applied carefully and lightly, give relief to the pain. The propriety 
of prescribing opium or morphia has given rise to much diflerence of 
opinion. It is sometimes impossible to refuse the patient the relief 
which it promises, but weight must be given to the argument ad- 
vanced by surgeons that by its use the symptoms are masked. If 
the propriety of laparotomy is under consideration, opium should not 
be given until the patient has been seen and examined by the opera- 
tor, and a decision has been come to either for or against surgical 
interference. In coming to this decision there ought to be as little 
delay as possible. There is, however, no objection to giving relief 
even to the extent of masking the symptoms, if an accurate diagnosis 
of the cause of the peritonitis has been made. 

Chronic peritonitis not due to tuberculosis is a very rare affection. 
Since the possibility of recovery from tuberculous aflections has been 
more generally recognized its existence has been denied, and it is cer- 
tainly exceedingly difficult in the great majority of cases to exclude 
tuberculosis. It is an occasional consequence of acute traumatic peri- 
tonitis, and a rare sequel of measles. It may be produced by diseases 
of the spleen and liver, especially hydatid, by typhlitis, by chronic 
heart disease. Hepatic cirrhosis must also be enumerated among the 
causes of chronic peritonitis. When due to disease of one of the 
abdominal organs, it is, at first at least, localized. Cases are met with 



CHUOSIC PERITOXITIS. 349 

occasionally, especially in girls at puberty, but also iu young cbildren, 
in >vhich considerable ascitic ct!\isiou occurs without obvious cause, 
ami it is usual to attribute the etlusion to chronic peritonitis, >vhich 
is then termed idioi)athic. The term is, however, a confession of 
ignorance. After the tluid has been absorbed, or perhaps drawn off 
on more than one occasion, the belly becomes tense, and generally 
resonant, but patches of dulucss remain, and hard masses maybe felt; 
these are supposed to be due to thickening between adjacent adherent 
coils. The majority of such cases are without much doubt tubercu- 
lous. When due to injury or to disease of one of the abdominal 
organs, chronic peritonitis is at first localized and plastic. The 
amount of fluid effusion is small, but the tendency to adhesion is 
marked. In this way organs may be bound down in abnormal posi- 
tions, and bands formed which may eventually be the cause of in- 
ternal strangulation. The great omentum may become deformed and 
retracted. 

The symptoms of chronic peritonitis vary with the nature and 
vAtent of the lesion. In chronic peritonitis after measles, and in the 
" idiopathic " form, the fii^st thing to attract attention is the enlarge- 
ment of the abdomen, which is found to be due to fluid. In these, 
and in the traumatic cases also, it may be impossible to elicit any 
Listen^ of pain or evidence of tenderness. In local peritonitis local 
pain and tenderness with increased resistance, or an ill-defined tumor, 
may l>e present, but it appears certain that in many cases the symptoms 
are so slight that medical advice is not sought. 

The effects of treatment directed to the local condition are not, as 
a rule, well marked. Counter-irritation with iodine may be tried, 
one-quarter of the abdominal surface being painted with tincture or 
liniment. Painting with iodoform collodion has been recommended, 
and advantage sometimes appears to be derived from the use, for a 
week or ten days, of mercurial ointment rubbed gently into the belly 
and then covered with a bandage. In any case, but especially when 
there is much ascites, a broad flannel bandage should be firmly applied 
next to the skin, and worn night and day, and the tliighs and legs 
should be kept warm. When the amount of fluid effused is large 
enough to distend the abdomen the operation of paracentesis should 
not be too long delayed, and should be repeated, if necessary, without 
hesitation. Should thefluid withdrawn be purulent, it can liardly be 
doubted that an exploratory laparotomy ought to be performed with 
the view of evacuating the pus, which will probably be contained not 
in the general peritoneal cavity but in a part limited by adiiesions. 
Chronic }K*ritonitis, however, attended by suppuration, is, in ver)' 
many cases, tuV>erculous. Internal remedies, such as potassium iodide, 
have little or no influence on the local condition, and exercise a de- 
pressing effect on the general health. The main point to be kept in 



350 PERITONITIS. 

view is to maintain the general nutrition by supplying easily digested 
food, especially milk, meat (including chicken and fish), and fats 
(butter and bacon). 

Appendicular Peritonitis. — The vermiform appendix is in man an 
obsolete and functionless organ ; its length, in proportion to that of 
the large intestine, is greater in the infant (one to ten) than in the 
adult (one to twenty). Its actual length is about 1 in. at birth, 
about 3 in. at five years old, and about 3 J in. at ten years old ; it 
attains its maximum length (under 4 in.) before the age of twenty. 
Its position varies. In about one-third it runs up along the left border 
of the caecum, in another third it lies either behind the caecum or in 
intimate relation with it. In about one-sixth it hangs down into the 
pelvis, and in a few it runs transversely across the psoas and may 
reach the left side. 

It is liable to inflammation of its mucous and other coats, and this 
liability is greater under twenty years of age than above. In the 
series of cases recorded by Hawkins ^ at all ages from five upwards, 
11.6 per cent, occurred between five and ten years, and 43.3 per 
cent, between ten and twenty, but it may occur in infancy, and is 
altogether probably more frequent in childhood than is generally 
recognized. 

Catarrhal inflammation is probably common, but produces no 
symptoms unless the peritoneal coat become involved. It may end 
in (1) recovery. (2) In obliteration owing to shedding of the epi- 
thelium ; a granulating surface is produced which leads to complete 
occlusion throughout its whole extent, or a limited stricture followed 
by cystic dilatation of the part beyond. This is rare in children. 
(3) A chronic condition, with great thickening, so that the appendix 
cannot collapse and become obliterated, but remains patent, secret- 
ing pus. 

Ulceration may be a consequence of catarrh, or may be produced 
by a faecal concretion, far more rarely by a foreign body, such as the 
traditional cherry stone. The appendix, especially in children, ap- 
pears usually to contain some faeces, but under pathological conditions a 
small mass may be retained, and in time become coated with lime 
salts. The ulceration may lead to peritonitis and perforation. 

Infective appendicitis may be primary or may succeed catarrh or 
ulceration. It is an acute inflammation involving all the coats, and 
may begin apparently either in the mucous membrane or in the sub- 
mucosa. It may affect a larger or smaller area, and may end (1) in 
necrosis, causing a local perforation not necessarily connected with 
the lumen of the appendix ; (2) in detachment of the appendix, if 
the necrosis involves the whole circumference ; or (3) in completed 
gangrene of the whole organ. It is due to micro-organisms, amongw 
^ "Diseases of the Vermiform Appendix," London, 1895. 



i 



APPEXDICULAR FERITOMTIS. 351 

which the bacillus coli communis is that most often found, though it 
seems probable that in the initial stage at least the active agent is one 
of the pyogenic streptococci. The importance of iniiammation of 
the appendix lies entirely in the risk of the production of peritonitis. 
Obviously this risk varies "svith the nature of the primary lesion. 
Thus chronic catarrh or stricture with cystic dilatation gives rise 
most commonly to local adhesive peritonitis : acute inflammatory 
necrosis, and ulceration due to concretion, may cause either acute 
local peritonitis with formation of pus (perityphlitic abscess) or acute 
general [>eritonitis. 

In cases of local adhesive peritonitis there is, as a rule, no discover- 
able determining cause, but occasionally the onset is preceded by a 
meal of indigestible food, or by a blow or strain. Pain comes on 
rapidly, sometimes so suddenly that the child cries out as though 
struck. It is referred, as a rule, to the right iliac fossa, but may at 
first be diliused over the abdomen, and localized only on the second 
day. It radiates towards the umbilicus, and may extend to the front 
of the thigh in the region supplied by the anterior crural nerve. 
Vomiting may occur once or twice at the onset, and constipation due 
to paralysis of the gut is the rule from an early stage, though two or 
three motions may be passed at the onset. The temperature rises at 
once, and commonly attains its maximum on the first day. It is ac- 
companied by a good deal of general depression, which may even 
amount to collapse. The pulse is quickened in proportion to the 
fever. The tongue is furred but moist, and there is anorexia. The 
right thigh is flexed upon the abdomen, and attempts to extend it 
cause severe pain. AVith rest the pain subsides in the course of a 
few days, but marked local tenderness persists somewhat longer. It 
is usually most marked at McBurney's point (about halfway between 
the anterior superior iliac spine and the umbilicus). It may extend 
over the whole of the right lower quadrant of the abdomen and as 
high as the ribs. At first palpation discloses no more than increased 
resistance in this area, due to rigid contraction of the abdominal 
muscles, but as the acute process subsides a soft, ill-defined swelling 
may usually be felt, generally oval in form, with its long diameter 
parallel with the outer part of Poupart's ligament. Should the ap- 
pendix occupy one of the less usual positions mentioned alx)ve, the 
area of tenderness and the swelling will be displaced correspondingly. 
The tumor is due to congestion and swelling of the ca?cum and the 
lower part of the ileum, with fibrinous exudation between the coils ; its 
bulk is frequently increased by some fiecal accumulation. Resonance 
over the swelling is generally but not invariably diminished. In a sim- 
ple attack of this nature the temix-rature usually falls to normal about 
the seventh day, and the patient is convalescent in ten days or a fort- 
night, but similar attacks may recur at more or less frequent intervals. 



352 



PERITONITIS. 



Perityphlitic Abscess. — The early symptoms in a case in which 
suppuration eventually occurs are identical with those just described, 
and may not be exceptionally severe. Suppuration may begin as 
early as the fourth day, but this is unusual ; its occurrence is indicated 
by the rapid formation of a large tumor, harder and better defined 
than in simple adhesive peritonitis. In less acute cases the persist- 
ence, or even the increase in size of the swelling after a week or ten 
days have passed, and the increase of tenderness will suggest the 
presence of suppuration. The temperature is also of assistance since 
when suppuration occurs the normal fall on the sixth or seventh day 



Fig. 54. 




Temperature chart of a case of simple Appendicular Peritonitis in a child aged 14. (Hawkins 
Diseases of the Vermiform Appendix.") 



does not take place, or it is iuterrui^ted by a secondary rise which 
presents the morning remissions and evening exacerbations commonly 
produced by suppuration. Examination under chloroform, which in 
doubtful cases should never be omitted, may reveal fluctuation, and 
render a positive definite diagnosis possible. Apart from fluctuation, 
to the absence of which not much weight can be attached, the most 
reliable signs of suppuration are the character of the temperature and 
the increased tenderness, since a swelling persisting for several weeks 
may be due to a mass of thickened adherent omentum. In rare cases 
only will the continuous temperature be due to one of the complica- 



ACUTE GENERAL PERITONITIS. 353 

tions of perityphlitio abscess, such as infective thrombosis of the por- 
tal vein and liepatic abscess. Perityphlitio abscess may ruptnre into 
the gut, or it may }x>int at the surface, leading in some instances to 
fjecal fistula. Inliammation of the psoas muscle may occur, and may 
account for long-pei*sistent Hexion of the hip. The most serious com- 
plication is intestinal obstruction due to kinking of the small intestine, 
prcxluced by adhesion of one of its coils to the imflanunatory mass in 
the left iliac fossa. 

Acute general peritonitis due to inflammation of the appendix 
generally comes on ijuite suddenly in the midst of apparent health, 
and in a child who has never presented any symptoms referable to 
the appendix. In some cases the history renders it probable that 
peritonitis, which might have been localized, is made general by the 
administration of violent purgatives as soon as comjdaint was made 
of pain in the abdomen. The symptoms do not differ from those of 
general peritonitis from other causes — general abdominal pain and 
acute tenderness and distension, followed within twenty-four hours 
by arrest of the abdominal respiratory movements. The pain is not 
localized, and its onset is followed quickly by vomiting. The mouth 
becomes drv, thirst is extreme, and the tongue is furred ; the urine 
is sciuity, and often contains albumen ; the pulse is quick ; the tem- 
perature rises rapidly to 102° or 103°, but usually falls before 
death ; the fice is pinched and anxious, and the patient retains con- 
sciousness until shortly before death, when anxiety is replaced by 
apathy and somnolence. Both legs are drawn up, and in the less 
-I'Mte cases evidence of fluid in the abdomen may be discovered. 

Tile diagnosis of localized peritonitis due to inflammation of the 
appendix is not, as a rule, difficult. From intussusception it is dis- 
tinguished by the fact that in this condition the tenderness and signs 
of local {XTitonitis are not early symptoms ; that the tumor, if discov- 
erable, is found in the middle line or towards the left, and seldom 
occupies the right iliac fossa, where the sense of resistance is dimin- 
ishes!, or at least not increased ; and that tenesmus is an early and 
prominent symptom. Faecal accumulations may produce pain, vom- 
iting, constipation, and slight fever. The constipation may be re- 
place<l by diarrhrca, or at least by the passage of frequent small 
stools, but the diagnosis in the early stage and on a single examina- 
tion is often diffieult. The pain is colicky and intermittent, and in 
place of muscular rigidity in the right iliac fossa there is in this or 
some other region a distinct tumor, which is not tender, though 
colic may be determined by its manipulation. [A blood count 
is here of great value, and leucocytosis, if it be found, points 
strongly towards appendicitis esix'cially if several different counts 
show an increasing number of whites. In the most severe cases of 
appendicitis, however, there may be no leucocytosis, absence of which 
23 



354 PERITONITIS. 

in such eases, is a grave prognostic sign.] Probably the condition 
with whicli appendicular peritonitis is most often confounded is dis- 
ease of the right hip joint, which it resembles owing to the flexion 
of the hip, the limp in walking, and the pain produced by handling 
the limb. It will be found, however, in appendicular disease that 
though the thigh cannot be extended without causing acute pain, it 
can be rotated without complaint ; tliat there is no tenderness behind 
the trochanter, and no wasting of the muscles of the thigh or dis- 
placement of the gluteal fold ; and that the child while lying down 
will spontaneously increase the flexion of the joint or permit this to 
be done, without giving any signs of suffering. Abscess in the iliac 
fossa from other causes must be borne in mind. Among these may 
be enumerated caries of the spine or of the innominate bone, disease 
of the sacro-iliac joint, empyema tracking downwards, and super- 
ficial abscess, the result of injury ; perinephritic abscess, though a 
very rare condition in children, may also be mentioned. The history, 
w^iich in the majority of the conditions enumerated is prolonged, in 
contrast with the sudden onset of appendicular peritonitis, will assist 
in the diagnosis, which, however, can usually be made with cer- 
tainty only after careful physical examination under chloroform. 

The treatment of local peritonitis due to appendicular disease 
should consist of rest in bed, with a pillow under the knee on the 
affected side, the application of poultices or fomentations, or of an ice 
bag to the right iliac fossa to relieve pain, and the administration of 
opium (Ulij every four hours to a child of five) or of opium and 
belladonna if vomiting is troublesome. A hypodermic injection of 
morphine (gr. Jg ) may be given, but in either case it is unnecessary, 
and certainly undesirable, to continue the use of opiates for more 
than two days. No purgative or laxative medicine should be given 
but if it appears desirable to solicit an action of the bowels, and this 
should not be done until pain has subsided and convalescence is 
commencing, a glycerine suppository or a small glycerine enema 
(oj to 5ij), or a simple soap enema, should be given. The manage- 
ment of convalescence is of great importance. Absolute rest in bed 
is essential, but though it is easy to keep a child in bed, it is diffi- 
cult to keep a robust boy at rest after the local pain and tenderness 
have subsided. For this reason it has seemed to me advisable to 
apply a long splint for a week or a fortnight. During convalescence 
purgatives should be avoided, and at most a mild saline aperient 
should be given if an enema is deemed insufficient. When there is 
evidence of suppuration, or when there is reason to suspect it, and 
the patient's general condition is deteriorating, surgical interference 
should not be delayed. While the temperature is elevated, and until 
convalescence is completely established, the diet should be fluid, and 
in the early stage at least pancreatized milk, or some other form of 



m 



ACUTE GENERAL PERITONITIS. 355 

predigested food, is to be preferred. The treatment of general peri- 
tonitis must be directed to maintaining the strength and relieving 
pain. The nse of saline laxatives, which has fonnd much favor in 
peritonitis due to other causes, is contraindicated, and the too free 
administration of opium masks the symptoms. In 9 of the 30 cases 
observed by Hawkins recovery ensued. In 11 cases the abdomen 
M'as opened, the pus and infianimatory products within reacli of the 
incision removed, and an attempt made to wash out the whole 
abdominal cavity ; none of these cases recovered, so that this, which 
seems to be the most rational treatment when the diagnosis of appen- 
dicular disease can bo made with an approach to certainty, should 
only be adopted after the most careful consideration. 



CHAPTER XXX. 
DISEASES OF THE LIVER. 

Jaundice — Catarrhal Jaundice — Infective Jaundice — Acute Yellow Atrophy — Cir- 
rhosis — Amyloid Degeneration — Fatty Infiltration — Fatty Degeneration — Sup- 
purative Hepatitis. 

Pathological and clinical conceptions as to diseases of the liver 
are so incomplete and so governed by tradition that it is difficult to 
arrive at a satisfactory classification. The liver^ like other glandular 
organs, consists of a secreting epithelium, excretory ducts, and blood- 
vessels, though the blood supply presents certain well-known pecu- 
liarities related to the assimilative functions of the gland. Any one 
of these parts may be the primary seat of morbid changes of in- 
flammatory or degenerative type. Thus there may be catarrhal in- 
flammation of the bile ducts causing catarrhal jaundice, purulent 
inflammation leading to suppuration and abscess of the liver, or 
fibrosis producing so-called biliary cirrhosis. The glandular sub- 
stance itself is liable to acnte degeneration, probably of the nature 
of infective inflammation, of which acute yellow atrophy is the best 
known and most marked form ; to fatty degeneration ; to fatty in- 
filtration ; and to atrophy by compression produced by fibrous over- 
growth. The blood-vessels are liable to infective inflammation 
(pylephlebitis), producing disseminated abscesses, and to fibrous 
overgrowth of their connective tissue sheaths leading to cirrhosis. 

The double function of the liver as an assimilative and a secreting 
organ is disturbed to a greater or lesser extent by affection of any 
of its parts, but most profoundly by aflections oi the hepatic cells. 
Thus we have on the one hand imperfect assimilation, especially of 
fats and carbohydrates, and on the other imperfect formation of bile, 
or retention and absorption, jaundice being in either case produced. 

Jaundice is due to absorption in the liver of bile pigment which 
is carried by the blood to all the organs and tissues of the body. 
Bile salts and certain toxins are also absorbed. Bilirubin is itself 
toxic, producing extreme slowing of the heart and a fall of blood 
pressure. Bile salts have a similar but less marked action. Biliru- 
bin is the pigment absorbed in ordinary cases of catarrhal jaundice. 
When the hepatic glandular substance is aflected primarily, its pro- 
duction of pigment is imperfect and urobilin is formed, absorbed, 

356 



1 



CATARRHAL JAUNDICE. 357 

and excreted in the urine. This abnormality in the functions of the 
hepatic cells is attended bv other changes in the constitution of the 
bile, which favor the absorption of bile pigments independently of 
obstruction of the bile ducts. Among these should be mentioned a 
thickening of the bile, which causes it to flow less easily. 

Wiien the functions of the liver are deranged suddenly there is a 
disturbance of nitrogenous metabolism, and a diminution in the ex- 
cretion of urea by the urine, except in extreme cases (acute yellow 
atrophy), when there is at lirst an excess of urea, together with the 
appearance of products of imperfect metabolism (leucin, tyrosin, 
xanthine, etc.), which subsctpiently replace urea almost entirely. 
With the restoration of the functions of the liver there is a large in- 
crease in the urea, in the bulk of the urine, and in the proportion of 
toxins which it contains. Bile salts are seldom present in the urine, 
except in the terminal stage of acute yellow atrophy. The extent 
to which the assimilative functions may be deranged is shown by the 
fact that in some cases there may be temporary glycosuria attendant 
upon the ingestion of carbohydrates (alimentary glycosuria). 

The liver also is liable to become infected by tuberculosis and 
syphilis, to be the seat of hydatids (see page 407) and of new growths, 
though these are of very rare occurrence in childhood. It may be 
useful to insert here the following classification of morbid processes 
to which the liver is liable, though it will not be convenient to follow 
the arrangement closely in the following jiages : — 

Affections of bile channels Catarrhal jaundice. 

Infective catarrhal jaundice. 

Purulent Inflammation, abscess. 

Biliary cirrhosis. 
Affections of hepatic cells Infective jaundice. 

Acute yellow atroithy. 
Affections of blood-vessels Cirrhosis. 

Pylephlebitis. 
Syphilis. 
Tuberculosis. 
Hydatid disease. 
New growths. 

Catarrhal jaundice is by no means uncommon in children ; it 
may occur in infancy, but is comparatively rare under three years. 
Occasionally it prevails in an epidemic manner. 

The majority of cases of simple jaundice, in children as in adults, 
are due no doubt to catarrhal inflammation, more or less severe and 
extensive, of the bile duct and pos.sibly of its tributaries. This 
angiocholitis, which is usually associat<xl with duodenal catarrh, and 
preceded by gastric catarrh, produces a thickening of the mucous 
lining, which Ixjcomes injected and gelatinous, and .secretes an ab- 
normal amount of tenacious mucus. Among the causes predisposing 



358 DISEASES OF THE LIVER. 

to catarrhal jaundice must be reckoned errors in diet, excessive 
quantities of fatty and nitrogenous foods, and alcohol, which is by- 
some parents given in considerable quantities at a very early age. 
In other cases exposure to emanations from foul drains or from col- 
lections of decomposing animal matters, or bathing in sewage-polluted 
rivers, has appeared to be the determining cause of the jaundice. 
The cause of an epidemic of jaundice has usually been found in some 
such conditions as those just enumerated. In some cases, of which 
those due to the causes last mentioned perhaps constitute the majority, 
the jaundice is due to a progressive infection, which involves not only 
the bile vessels but also the hepatic cells. This affection, though 
graver than ordinary catarrhal jaundice from retention, presents 
symptoms which are of the same kind but more marked, especially 
at the onset. 

The characteristic symptoms of catarrhal jaundice are preceded 
usually for three or four days by malaise, headache, loss of appetite, 
gastric uneasiness, and nausea, which may lead to vomiting. The 
tongue is large, covered with a thick white fur, and the breath is 
very offensive. These symptoms may have passed away, and the 
tongue may have become clean before the icteric tint is noticeable. 
The characteristic golden-yellow staining of the integumentary 
structures will be seen first over the sclerotics, then on the lips, the 
hard palate, the corners of the mouth, the temples and forehead ; a 
little later it becomes evident over the trunk, and last on the ex- 
tremities. Some twenty-four hours before any pigmentation can be 
noticed the urine will have contained bile pigments, which impart to 
it a color varying from a greenish-yellow to a dark brown. Both 
the quantity of urine and urea is diminished. The pigment is taken 
up by the cells of the Malpighian layer of the skin, and retained by 
them probably until they are exfoliated, so that the yellow coloration 
persists for two or three weeks after its cause has been removed. 
All the organs of the body, with the exception of the central nervous 
system, are bile-stained. The liver is a little enlarged, tender on 
firm pressure, and soft. The faeces, which are usually pasty, are of 
a light color, so that they are compared to moist clay. The want of 
color is due in part to the absence of bile pigment, and in part to the 
presence of an excessive quantity of fat which, in the absence of the 
bile from the intestine, is imperfectly absorbed. More than half the 
fat ingested may be eliminated with the faeces. The stools have an 
offensive odor of putrefaction, and the aromatic sulphates of the 
urine, which vary directly with the amount of intestinal putrefaction, 
are increased. The slowing of the pulse, which is a marked and 
constant symptom in adults, is, as Henoch has observed, not often 
noticeable in young children, owing perhaps to the nervous excite- 
ment which a medical examination causes in them. Pruritus also, 



lyFECTIVE JAUNDICE. 359 

which is frequently the most distressing symptom in adults, is often 
absent in children. Of the subjective symptoms, the most marked 
are mental depression, heaviness, and drowsiness. Complaint is 
often made of a sense of fulness in the hepatic region, of a bitter taste 
in the mouth, and in a few rare cases xanthopsia has been definitely 
present, owing apparently to affection of the cerebral centres. On 
the whole, however, the symptoms, both those which precede and 
those which accompany the jaundice, are slight, and medical aid is 
of\en sought only when the yellow tint has become well established, 
and the patient is. in flict, already convalescent. 

Infective Jaundice.^ — The presence or absence of fever is a point 
of much interest and importance. In the greater number of cases 
no elevation of temperature occurs, or it is very slight and of short 
duration. In others there is very well-marked pyrexia in the early 
stage. Such ceases are of a more severe type in other respects ; they 
are met with most often during epidemics ; and there is probably 
some involvement of the hepatic glandular tissue in the infective proc- 
ess. A day or two after the exj^osure to the supposed cause, or even 
after a shorter interval, the patient begins to suffer from aching pains 
in the joints and back : from depression, loss of appetite, nausea or 
vomiting, giddiness, and a bitter taste. The temperature is found to 
be raised, and ranges for some days between 101° and 103° F. 
The urine is scanty and high-colored, the spleen is enlarged, the liver 
enlarged and tender, epistaxis sometimes occurs, and there is often 
an outbreak of herpes labialis. After five or six days jaundice ap- 
pears, the fever abates, large quantities of urine containing much 
urea are passed, and the general condition improves rapidly. At or 
about the time at which the jaundice appears the ftieces becomes clay- 
colored, but, as a rule, convalescence is not interrupted. 

There is another variety of infectious jaundice to which Chauffard ^ 
projx)ses to apply the term ^^ pleioehromic.^^ It is of the same type 
as the form last mentioned, but more severe. There is a primary 
affection of the hepatic glandular tissue, causing an alteration in 
the chemical constitution of the bile, and an excess of coloring 
matter which is absorbed and jiroduces jaundice, though there is no 
retention, and the fa?ces are dark-colored. The patient is taken ill 
suddenly with headache, aching in the limbs and back, fever, loss of 
apjX'tite, nausea, often vomiting, and enlargement of the spleen and 
albuminuria. There may be slight wandering delirium, and the 
general resem})lance to typhoid fever may be very close. On the 
fiflh or sixth day jaundice appears, accompanied often by petechia?, 

' I)r. William Hiintor s article in Prof. Clifford AlUmtt's " System of Medicine," 
pablbhecl while these pages were jiassing through the |trej«8, deals with this and cog- 
nate wibject."* in a masterly manner. 

« "Traite de M^." (Charcot, Bouchard, Bonillaud), p. 754. 



360 



DISEASES OF THE LIVER. 



by epistaxis, and by bilious diarrhoea. Two or three days later the 
temperature falls ; a large quantity of urea is eliminated in the 
urine, which becomes copious and free from bile pigment and from 
albumen. The faeces becomes normal, and the patient recovers 
slowly. In some cases convalescence is interrupted in a week or 
less by a relapse. Herpes of the lips has been observed, and a 
roseolar or scarlatiniform rash has been met with during the pyrexial 
period, and severe urticaria at its close. This is a picture of an in- 
fective disease, and Ducamp states that it has an incubation period 
of five days. The resemblance of the symptoms of the early stage 
to typhoid fever has been mentioned, and the disease has been sup- 
posed to be due to a special localization of the typhoid bacillus in 
the liver and bile channels. Direct evidence on this head is want- 
ing. Such as exists is, on the whole, opposed to the theory, al- 
though there are good grounds for believing that the infective agent 
is derived from water or air contaminated by sewage or the products 
of the putrefaction of animal matters. Chauffard^s view that the 
" new infectious disease '^ described by Weil^ and known as WeiPs 
Disease, is identical with this form of jaundice appears to be well 
grounded. The severe forms of icterus neonatorum [q, v.) associated 
with septic infection belong to the same class, the jaundice being due 
to an infective lesion of the hepatic cells. 

As the final term of this series of hepatic disorders we have acute 
yellow atrophy of the liver, in which there is a rapid granular degen- 
eration of the hepatic cells, and consequent shrinking of the whole 
organ. There is coincident glomerulo-nephritis and enlargement of 
the spleen. The onset may be sudden or insidious, and the symptoms 
resemble those of the form last described, but are more intense. The 
faeces after a time lose their bilious color, owing to the arrest of the 
secretion of bile due to the progressive destruction of the hepatic 
glandular tissue. There is pain and tenderness in the hepatic region, 
and rapid diminution in the area of hepatic dulness. The tempera- 
ture, elevated at first, tends to fall after the first six or seven days, 
while the pulse which is small and soft, becomes progressively more 
rapid. The urine is scanty, and contains at first an excess of 
urea, but subsequently urea almost disappears, its place being taken 
by leucin, tyrosin, etc. The blood, which is dark and does not 
coagulate readily, also contains large quantities of these products 
of imperfect nitrogenous metabolism. The disease, which is ex- 
tremely rare in childhood, is due probably to an infective agent 
derived from insanitary surroundings ; among predisposing causes 
are alcoholism and syphilis. 

The prognosis of simple catarrhal jaundice is good, and in the more 
severe forms it is not unfavorable, especially in children, in whom 
the alcoholic habit is seldom confirmed. Previous disease of the 



d 



CIERHOSIS OF THE LIVER. 361 

kidneys is an nnfovorable element in pi\)gnosis, sinee the danoer to 
life lies in the retention of toxins whieh are j^roclueed owing to tlie 
deficient functional activity of the liver ; when the kidneys are healthy 
these are eliminated rapidly. The prognosis is less favorable when 
there is well-marked fever and when the stools are bilious, but re- 
covery is the rule, except in acute yellow atrophy, which is a very 
fatal disease. 

The treatment of simple catarrhal jaundice is directed to the re- 
moval of the obstruction, and to the prevention of intestinal putre- 
faction and the absorption of toxic production. Calomel in small 
doses, fre<juently repeated, is a valuable drug, since it not only stim- 
ulates ])eristalsis but exercises an antiseptic action, owing probably 
to the perch loride of mercury which it contains in small quantities. 
Salol, naphthol, beuzonaphthol, and salicylate of bismuth also are 
useful to correct the putrefaction of the intestinal contents. Chauffard 
recommends a combination of salicylate of naphthol with salol, since 
these drugs are not only intestinal antiseptics but also cause the ap- 
pearance in the bile of salicylic derivatives, which have an antiseptic 
action on the bile channels. Later, when the feces begin again to 
be of natural color, a mixture containing hydrochloric or nitro-hydro- 
chloric acid should be given, and a small dose of liquor strychninie or 
tincture of nux vomica is a useful addition. The use of rhubarb in 
various combinations, and of senna, which was very popular, appears 
to offer no advantages which compensate for the nauseous flavor of 
these drugs, and in a condition such as this, when the object should 
be to promote appetite and improve digestion, prescriptions cannot 
be too simple. The food should be very simple, and the greatest 
advantage is to l)e derived from a diet consisting exclusively of milk 
or skim milk and whey. It is sufficient and simple, while it has 
a diuretic action which is desirable. As beverages, freshly-made 
lemonade, lemonade made with barley-water, or the Imperial drink 
may l>e permitted, but all alcoholic drinks should be forbidden. 
Meat should not be permitted, and the use of brotiis and beef-tea is 
better avoide<:l. The patient should at first l)e ke})t at rest, and con- 
fined to bed should there l)e any fever. Later, regular exercise should 
be prescribed, and should the liver continue tender or a tendency to 
constipation remain, a course of saline laxatives, either at home or at 
a spa, should l)e j)rescribed. 

In the graver forms of jaundice, and in acute yellow atrophy, the 
indications for treatment are the same. Owing to the fact that the 
disease is attended by deficient oxidation of nitrogenous bodies (elim- 
ination of leucin, tyrosin, etc.), inhalation of oxygen and the internal 
administration of drugs believed to favor oxidation, such as benzoate 
of ««»flM. liavf boon reoommended. 

Cirrhosis of the liver is a rare disease in childhood. Alcoholism, 



362 DISEASES OF THE LIVER. 

the commonest single cause, accounts for about one-sixth of the cases* 
The production of fibrosis of the liver by syphilis and by tuberculosis 
accounts for about one-fifth of the cases. Of the remainder the 
major part occur as sequelae of acute infectious diseases, especially 
scarlet fever and measles. 

Most of the cases are examples of portal fibrosis, but the liver is 
more often large (hypertrophic) than contracted. The organ is large 
and heavy, its edge blunt, its color a gray or reddish yellow, its cut 
surface firm and finely granular. The large size of the liver is due 
mainly to the fact that the hepatic cells do not atrophy, nor does the 
fibrous growth retract. 

The prominent symptom, and that first noticed, is ascites ; the 
limbs are wasted, the skin has a waxy tint, and oedema of the lower 
extremities may be an early symptom. The subcutaneous veins of the; 
abdomen may become much dilated, forming four or five large trunks, 
which run down from the neighborhood of the xiphoid cartilage to 
the groin. They communicate above with the epigastric and internal 
mammary, and below with the iliac and saphenous veins. The course 
of the blood in them is from above downwards. This dilatation, 
commences later than ascites, and may persist long after it has ceased ; 
it is certain evidence of portal obstruction. The enlarged liver may 
be felt unless the ascites is extreme, and the spleen also is, as a rule, 
enlarged. The quantity of urine passed is small and the urea below, 
but the uric acid above, the normal. The nose bleeds easily, but 
epistaxis is not severe, whereas the patient is liable to severe gastro 
intestinal hsemorrhage. The stools are not pale, and diarrhoea is 
common. Chronic peritonitis may be associated with cirrhosis. 

The prognosis of hypertrophic fibrosis is fairly good if the case can 
be treated systematically from an early stage. 

The treatment must be directed in the first place to the removal of 
the cause, and in particular all alcoholic stimulants should be arrested. 
The patient should be put on a diet of milk, with skim milk or whey 
as a beverage, and the diuresis to which this diet predisposes encour- 
aged by diuretic drugs, of which the most valuable is calomel. It not 
only exerts a marked diuretic action but stimulates the hepatic cells, 
and possibly also tends to arrest the fibrosis. It should be given in 
small doses, gr. J-J daily. During the course of calomel antiseptic 
mouth washes should be used, and the teeth kept scrupulously clean. 
Potassium iodide has been used, but it is of doubtful value, and its 
effect must be carefully watched. Diarrhoea should not be checked 
unless very copious. If the amount of fluid in the peritoneum is 
large, it must be Avithdrawn by tapping, and the operation must be 
repeated when necessary. 

Hypertrophic biliary cirrhosis, due to fibroid proliferation in con- 
nection with the bile vessels, and characterized by enlargement 



J 



AMYLOID DEGENERATION, 363 

the liver and repeated attacks of jaundice, has been observed in 
childhood, but the number of recorded cases is very small. The 
liver is generally tender, there is no ascites, the fieces are soft, and 
of a gray, brown, or light yellow color. The spleen is enlarged. 
Haemorrhages from the nose and intestines are frequent and often 
severe. The urine contains bile pigment. The disease is progres- 
sive. The patient becomes exceedingly weak, and succumbs in one 
of the attacks of jaundice. The treatment which appeal's to offer 
the best hope is a milk diet, systematic use of intestinal antiseptics, 
and of minute doses (^^ calomel. 

Amyloid degeneration k}^ the liver is associated with syphilis, or 
with long-continueil suppuration of pulmonary cavities, of the 
pleura, of joints, bones, or glands (chronic tuberculosis). The im- 
provement which has taken place in surgical methods has rendered 
it less common than formerly. The degeneration begins in connec- 
tion with the capillaries and arterioles, which become enveloped in 
a sheath of homogeneous transparent material. This fact lends sup- 
port to the theory, which the etiology suggests, that the degenera- 
tion is due to some ix^culiarity of the blood, possibly to the presence 
in it of some toxin derived from the suppurating lesion. Later, the 
degeneration extends to the liver cells. The amyloid substance is a 
nitrogenous body and is very little subject to change. It is insol- 
uble in the gastric juice, in acids, and in alkalies, and it does not 
easily undergo decomix)sition by putrefaction. Treated with a weak 
solution of iodine it takes a dark walnut color, which is changed to 
blue, and finally to purple by sulphuric acid. The liver when 
affected by amyloid degeneration is large, firm, and painless, with 
rounded edge. The spleen is usually enlarged by a similar amyloid 
degeneration, which may affect other organs also, particularly the in- 
testinal mucous membrane. The patient makes no complaint with 
reference to the liver, and the condition is usually only discovered 
on physical examination, for which an indication is afforded by a 

terioration in the nutrition, and by clubbing of the fingers. 

Amyloid degeneration is not in itself susceptible of treatment. If 
its cause can be removed the patient rapidly improves, but from the 
nature of the determining causes such patients are seldom long- 
lived, though the part which the amyloid degeneration has in l>ring- 
ing about this result, and indee<l its fate subsequent to the arrest of 
the suppuration, is not well understood. The occurrence of this 
degeneration certainly renders the prognosis worse in those cases of 
int or lung disease in which it occurs. 

The enlargement of the liver, so often present in /vV/;r/.v, has been 
attributed to amyloid degeneration, Init in the majority of cases at 
least it is due to fatty infiltration of the liver cells, which causes a 
general enlargement of the organ. The substance of the liver is of 



364 DISEASES OF THE LIVER. 

a lighter color and softer consistency than natural. The quantity of 
fatty matter in such a liver may be increased to six and even ten 
times the normal. This condition, in which there is merely an in- 
filtration of fat to a large extent taking the place of the water of the 
liver, and in which there is not, in fact, any structural lesion, must 
be distinguished from fatty degeneration, which is a consequence of 
the granular degeneration, or cloudy swelling, which occurs in the 
majority of acute febrile diseases, including acute pulmonary phthisis. 
In this condition the fat is derived from a degeneration of the gland- 
ular protoplasm, and a similar degeneration may attack the epithelium 
of the blood-vessels and capillaries. 

Suppurative hepatitis is uncommon in children. It may be 
secondary to suppuration in connection with the appendix vermi- 
formis, or of the mesenteric glands in typhoid fever, to dysentery, or 
to pyaemia. In a few instances it has been caused by the entrance 
of a round worm into the bile passage. With this exception, in- 
deed, its causes are the same as in adults, and its symptoms and 
course are identical. 



CHAPTER XXXI. 

ACUTE DISORDERS OF THE GASTRO-IXTESTIXAL 

SYSTEM. 

Etiology — Dyspepsia — Catarrhal Enteritis — Gastro-intestinal Catarrli— Acute Ciastro- 
enteritis— Acute Summer Diarrhaw — [Bacteriology] — Cholera Infantum — Com- 
plications — Treatment. 

The gastro-intestinal mucous membrane is tlic largest gland 
in the body. In its pathologieal relations it presents certain analo- 
gies to the skin, since it is liable to be exposed to the direct action 
of irritating substances, and is constantly in relation with numerous 
bacteria. Some are harmless, perhaps even useful in digestion, 
though the bacillus coli communis and, possibly, others may under 
certain circumstances become pathogenic. Further, the food may 
contain microbes essentially pathogenic, as, for instance, the bacillus 
of tubercle, and that of typhoid fever. Poisonous substances may 
be introduced into the canal with food or drink, or may be produced 
within it by perversion of the process of digestion. These poisons 

ting on the mucous membrane may cause local irritation and dis- 
turbance of function, or catarrh, or they may be absorbed, and so 
priKluce genenil symptoms. In the latter alternative local lesions 
may not l)e produced, or they may be slight or late in making their 
appearance. Thus in many cases of even serious general disturb- 
ance traceable to the gastro-intestinal canal, the morbid changes in 
the mucous membrane are recognized with difficulty, if at all, and 
may be, and probably are, of secondary importance. The most seri- 
ous symptoms of such disorders are secondary not to lesions of the 
mucous membrane but to the absorption of poisonous substances in- 
tnxluced into the alimentary canal, or produced within it. 

Gastro-intestinal disorders may also be sccoiKhin/ to general dis- 
eases, esj)ecially the acute infectious diseases, as, for instance, measles, 
and are then produced either by the action of the si>ecific infection on 
the mucous membrane, or by the elimination of toxic lx)dies through it. 
It may be the site of specific infections, as in enteric fever and 
tuberculosis, of new growths, or of parasites. Disturbance of its 
functions may be due to derangement of the; nervous mechanism. 
Malformations and malpositions, congenital or acquired, may under 
certain circumstances give rise to serious symptoms. 

365 



366 ACUTE DISORBEBS OF GASTRO-IJSTESTINAL SYSTEM. 

At the present time it is not possible to make a rational classifica- 
tion of gastro-intestinal disorders^ founded either upon morbid anat- 
omy or on the nature of the bacterial infection which undoubtedly 
has a large share in producing diseases having their origin in this 
tract. The attempt to found a classification on the presence or ab- 
sence of inflammation is not successful because, in the first place, the 
<juestion Avhether inflammatory changes are to be observed depends 
in many cases, if not in the majority, on the duration of the disease, 
such changes making their appearance if the patient survive the 
severe general symptoms produced by the absorption of toxic bodies, 
which are the true materies morbi ; and because, in the second place, 
it may be difficult to decide whether certain slight changes observed 
in more chronic cases ought to be regarded as inflammatory or de- 
generative.^ On the whole, it will be found most advantageous to 
follow clinical features, which are, as a rule, related to certain etio- 
logical factors to be more or less clearly discerned. 

The diet may be imperfect in more than one way. Thus (1) there 
may be deficiency or excess in the amount of food given, or in the 
proportion in which certain constituents are present in it. For ex- 
ample, cow's milk diluted to reduce the quantity of albumen to that 
present in human milk contains too little fat and milk-sugar, and the 
diet of ^' tea '' and bread-and-butter, on which too many children 
are fed immediately after weaning, is deficient in proteid and in fat. 

(2) The food may have undergone fermentative changes. Sour 
milk, milk '^ on the turn,'' meat which has undergone putrefactive 
and other allied changes, and bad fruit come under this category. 

(3) The food given, though of good quality, may be uusuited to 
the digestive powers of an infant or child newly weaned ; for ex- 
ample, solid meat, green vegetables, potatoes, and the ordinary food 
of the table. Such a diet is, moreover, usually deficient in certain 
constituents, especially fat. 

In infants at the breast over-feeding is the most common cause of 
dyspepsia. Too frequent suckling is the most common cause, but in 
exceptional cases the milk is itself too rich. The infant suffers from 
colic and flatulent distension ; it lies on its side, with its legs drawn 
up. It cries, and is suckled again to ^' pacify it." The bowels are 
at first constipated, but, later, a motion is passed usually after each 
suckling. This condition may usually be relieved by giving one or 
two doses of castor oil or liquorice powder, or calomel (gr. ss) to un- 
load the bowels, and by directing that the infant shall be suckled 
every three hours only. If the milk be too rich a little boiled water, 
about Sss, sweetened with milk-sugar should be given before each 
suckling. 

' Another and very real difficulty lies in the danger of mistaking post-mortem for 
pathological changes. 



GASTRO-ISTESTINAL MUCOUS MFMBRAKE. 367 

If the dyspepsia ]>ersist, a change is observed in the color of the 
stools. Avhich lose their goklen-yellow color, and become green. In 
the mildest cases the change in color takes place only after the stools 
have been passed ; in the more severe it occnrs within the intestine, but 
seldom higher up than the middle of tlie jejnnnm. It is due to the 
oxidation of bilirubin to biliverdiu, and is to be attributed, probably, 
to some alteration in the activity of the secreting organs, and not to 
the action of bacteria. The green color may cease spontaneously in 
a day or so, and may, indeed, recur several times before any other 
bvmptoms apjunir. It may occur before there is any evidence of 
ga-^trie irritation. As a rule, it is accomjxuiied by some increase in 
the number of the motions, which are more watery than in health. 
This is due to increased peristalsis, which hurries the ficcal matter 
througli the large intestine, where under normal circumstances it un- 
dergoes inspissation. These green stools, are commonly very acid, 
and often produce excoriation and intertrigo of the anus and but- 
tocks. 

If the cause of the disorder be not removed, the stools next be- 
come slimy owing to the secretion of an excessive quantity of mu- 
cus derived especially from the large intestine. At the same time, 
a considerable formation of gas produces distension and discomfort. 
It is passed often with the motions, which are in consequence expelled 
with explosive violence. These symptoms are attributed to catarrh, 
and tlie condition is often spoken of as catarrhal enteritis. Peri- 
stalsis becomes irregular and painful, and tlie infant is restless, kicks 
and struggles, or keeps the thighs drawn up to the belly. The at- 
tacks of painful colic cause sudden outcries, " screaming fits," and 
long ]K'riods of continued crying and whining. Symptoms of gas- 
tric irritation may supervene at any time. Appetite is diminislied, 
and the infant, after suckling eagerly for a minute or two, ceases and 
begins to cry owing to the painful colic which has been excited by 
the ingestion of the milk. The milk may be vomited immediately, 
or at a later hr>ur curds may be brought up, often in large masses, 
sometimes of a yellow color and mixed or coated with mucus. The 
normal increase of weight is checked at an early stage, then a loss 
of weight l^egins, and eventually extreme emaciation may ensue. 

The morbid cltaufjes to be observed in the intestines, in addition 
to the increased secretion of mucus, are that tlic superficial jxirts of 
the mucous membrane are, as it were, infiltrated with mucus, and 
that there is a considerable shedding of epithelial cells, which are 
entangled in the mucus with which the surface is covered. The 
contents of the small intestine are watery. The stools contain a 
large proportion of nitrogenous principles, though the actual daily 
V'-s of nitrogen by the bowels is not greatly increased. 

Green over-liquid stools should be treateA by alkalis to relieve 



368 ACUTE DISORDERS OF GASTRO-INTESTINAL SYSTEM. 

symptoms, and careful investigation should be made as to any errors 
in the suckling and clothing of the infant. The alkali used may be 
lime-Avater or sodium carbonate, or the old-fashioned powders of 

Fig. 55. 




Catarrhal swelling of the intestinal mucous membrane, with jiartial destruction and'detach- 
ment of superficial epithelial layers (early stage). (X 30.) 

rhubarb with soda or magnesia {e.g., Pulv. Rhei Co., gr. iij-v, t. d.). 
If the stools are slimy when the infant comes under treatment, it 
should be given a drachm of castor-oil to clear out the intestines, 

Fig. 56. 




Localized destruction of superficial layers of mucous membrane (later stage). (X 32.) (Pho- 
tomicrographs by Professor Baginsky. ) 



GASTJRO-IXTESTiyAL MUCOUS MEMBRAXE. 369 

and subsequently for a few days small doses of the same drug com- 
bined with an alkali, as in the ordinary castor-oil mixture. In some 
cases these may be replaced with advantage by small doses of mag- 
nesium sulphate. 

The severer forms of dys^x^psia and chronic catarrh are com- 
paratively rare in infnits reared at the breast, but in those brought 
up by hand dyspepsia is apt to become a serious disorder. It arises 
more frequently, its symptoms are more severe and less amenable to 
treatment, they lead to structural changes in the intestinal mucous 
membrane, and predispose to acute febrile diarrhtva and cholera in- 
fantum. The early stages may be the same as those already described 
in suckling infants, but the later stages of the disorder difter in 
nature and seat. 

In some cases symptoms referable mainly to the small intestine 
persist, and the infant gradually grows weaker. In others gastric 
symptoms become more prominent, and the strength is reduced more 
rapidly by frequent vomiting and complete anorexia. In others, 
again, the most pronounced symptoms are those of colitis. 

The course of the severer forms of gastro-intestinal catarrh is very 
inconstant. In the early stage arrest of the symptoms is followed 
by rapid improvement, but relapses are very apt to occur. In the 
later stages recovery is much more slow owing to impairment of di- 
gestion, and the liability to relapse is greater. Fever may be absent 
even down to a flital termination, but in other cases there is with 
each relapse or exacerbation a rise of temperature which lasts for a 
few hours or days. In others, again, especially those in which the 
symptoms point most distinctly to catarrh of the small intestine, re- 
mittent fever may persist for weeks, the thermometer rising in the 
evening to 100° or 101° F. AVhen exhaustion is great, however, 
the temperature is usually subnormal and may fall to 9o° or 9(3° F. 
In the most acute cases the infant becomes prostrate rapidly, and 
may die within two or three days ; in the mildest, convalescence is 
established within five or six days ; in the majority, however, the 
acute is followed by a subacute or chronic gastro-enteritis, which may 
last for weeks, months, or years. 

Acute gastro-enteritis may occur at any age, ])ut is met with i>er- 
haps most often in children two or three years old who have suffered 
since infancy from repeated attacks of gastro-intestinal catarrh. Xot 
infrefjuently, however, it comes on acutely in a child who has pre- 
viously enjoyed fairly good health. Such attacks may Ix? traced to 
chill, owing to insufficient clothing of the abdomen and lower limbs, 
or they occur during the summer months under conditions similar to 
those which produce cholera infantum. More rarely the condition 
is a complication or .sequela of one of the acute infectious diseases, 
especially measles. 
24 



370 ACUTE DISORDERS OF GASTRO-INTESTINAL SYSTEM. 

There is a general catarrhal inflammation of the ileum and colon, 
with shedding of the epithelium (Fig. 55) and infiltration into the 
mucous and submucous tissue. The cells of Lieberkiihn's crypts 
also undergo disintegration (Fig. 57), and finally there is a local 
destruction (epithelial necrosis) of the superficial layer of the mu- 
cous membrane (Fig. 56). Changes of a similar kind, but less 
severe, take place also as a rule in the mucous membrane of the 
stomach. In other cases the inflammatory process is from the com- 
mencement less superficial ; the mucous membrane is swollen owing 
to the infiltration of the submucosa with round cells (Fig. 58). The 

Fig. 57. 




Acute catarrhal enteritis. Disintegration of the epithelium of Lieberkiihn's crypts, (x 100.) 
(Photomicrograph bj' Professor Baglnsky. ) 



i| 



lymph follicles are the parts most affected, and the projection of the 
distended follicles (Fig. 60) gives to the mucous membrane a granular 
appearance. Finally the follicle breaks down and discharges through 
an aperture formed through the superficial layers of the mucous . 
membrane, and a small circular ulcer results (Fig. 59). To thisf I 
form the term follicular enteritis is applied. 

The onset of acute gastro-enteritis, when sudden, is often attended 
by vomiting, the temperature rises, and the child becomes restless 
and often perspires freely. It then has two or three motions con- 
sisting of fsecal masses suspended in a brownish fluid. After a short 



I 



GASTRO-INTESTIXAL MUCOUS MEMIiRAXE. 



371 



Fig. o8. 



Fig. 59. 




Acute follicular enteritis. Fig. 58, Swelling of intestinal wall due to infiltration of the sub- 
niucosa with round cells (early stage).'' . (X 32. ) Fig. 59, Follicular ulcer produced by necrosis and 
xtrusioD of a follicle (late stage). (Photomicrographs by Professor Baginsky.) 



Fic. r.o. 






Acute follicular enteritis. luilamuiaioiv awtlimg ui a fwllitk which i^ infiltrated and distended 
y round cells (early sUge;. ( X 20. ) ( Photomicrograph by Profe«.'»or Haginsky .) 



372 ACUTE DISORDERS OF G ASTRO- INTESTINAL SYSTEM. 

time the stools become slimy, streaked with blood, contain little 
feculent matter but often scraps of curd and other undigested par- 
ticles of food. The abdomen is distended, tympanitic, and a little 
tender in the course of the colon. In the more acute forms, to 
which the term acute dysentery is sometimes applied, the tenderness 
may be much greater and the pain seyere. Later, the motions, 
which are passed at yery frequent interyals, become small, brown or 
slightly bloodstained, and are often extremely offensiye in odor. 
Tenesmus is, in many cases, a source of much distress. 

Acute summer diarrhoea is the term commonly applied to the 
numerous cases of gastro-intestinal disorder attended by diarrhoea 
and yomiting which occur among children in large numbers, in tem- 
perate climates, during the warmer months. The attacks differ in 
character and yary greatly in severity. The common factor is the 
influence of a high air temperature sufficiently long continued to 
raise the temperature of the earth at a depth of 4 ft. to 56° F. 
This is attended by a great increase in the number and seyerity of 
the cases of acute gastro-enteritis such as may be encountered at any 
time of the year, and often by the occurrence of severe types wdiich 
are hardly, if at all, to be distinguished by their clinical course from 
Asiatic cholera. Cases of every intermediate degree of severity may 
be met with during periods of epidemic prevalence of diarrhoea. 
Taking all forms together, acute summer diarrhoea is the cause of a 
mortality among infants and children wdiich is always large, and is 
in some years and in some localities enormous. ISTearly half the 
cases occur in children under five years. 

Acute summer diarrhoea is favored by overcrow^diug and want of 
ventilation, and its incidence is most severe when the unhygienic 
conditions are combined with fouling of a porous soil, and the ac- 
cumulation of dirt within and filth w'ithout the houses. A high 
summer temperature produces its effect : (1) by its depressing in- 
fluence on the bodily powers, and the risk of chill while perspiring, 
or at sundown (a large number of cases begin during the night) ; (2) 
by stimulating bacterial growth in the soil and, possibly, in water ; 
and (3) by increasing the rapidity wdth which various processes of 
decomposition and fermentation occur in food, especially milk. Fre- 
quently (1) and (3) appear to combine to produce the attack. 

The relation of acute summer diarrhoea to microbial activity is, 
undoubtedly, intimate. Lesage has described a special group of cases 
characterized by green stools, which he attributes to infection of the 
intestines by a specific chromogenic organism. Fliigge has isolated 
a spore-bearing bacillus which he believes to have a specific patho- 
genic action. It is anaerobic, breaks up proteids with the produc- 
tion of toxic bodies capable of causing diarrhoea directly, and is very 
resistant. Baginsky, who has given much study to this subject, has 



II 



I 



ACUTE SUMMER DIABRHGEA. 373 

come to the oonolusion that there is no one specific microbe but that 
even in the most acute eases many saprophytic micro-organisms, 
having the power of producing decomposition, are present, and that 
in the intestinal canal they are pathogenic.^ Accepting this view, 
the tact that the large majority of infants who suffer are hand-fed 
leads us to the conclusion that the microbes, as a rule, enter the 
alimentary canal with the food, which is usually cow's milk or some 
mixture containing it. Further, in warm weather especially, the 
milk may, before it is swallowed, already have reached a rather ad- 
vanced stage of decomposition. Thus it may be found to contain 
lactic, formic, acetic, and butyric acids. Further, proteid decomj^o- 
-itions may have occurred with the production of jwisonous bodies, 
which have been shown experimentally to produce vomiting, purg- 
ing, and in doses sufficiently large, collapse and death.- Lastly, 
there is reason to believe that the ingestion of decomposing food, or 
the catarrh which it excites, may cause certain microbes, which in 
health are harmless occupants of the intestine, to become pathogenic, 
-specially the h. coli commidiia. 

[We would emphasize the importance of the relation between bac- 
terial activity and the intestinal affections of infants. While we 

• annot yet attribute to any specific organism a characteristic group 

• •f symptoms, it is along bacteriological lines that we must look for 
I rational classification of these intestinal disorders. 

Marfan maintains that all the organisms held responsible for 
-astro-intestinal disorders of nurslings are found under normal con- 
ditions in the digestive tract, but that under certain abnormal condi- 
tions, they become pathogenic. As already stated, most commonly 
are found the bacillus coli communis, and the b. lactis aerogenes, and 
more rarely the streptococcus, b. pyocyaneus, staphylococcus and 
certain peptonizing bacteria, tyrothrix, b. mesentericus. Under 
])athological conditions it is rare to find j)ure cultures of any of the 
above organisms; ^^ polymicrobism " is the rule. The most com- 
mon combination is the colon-bacillus and the streptococcus. 

The bacUluii coli communis is undoubtedly but one member of a 
group of bacteria, the individual differences of which are so slight 
'hat we cannot at present differentiate between them. It is a con- 
stant inhabitant of the intestinal tract, being found most a])un(lantly 
in the lower part of the small intestine and in the colon. Under 
normal conditifms it is non-])athogenic and causes an acid fermenta- 
tion. Under abnormal conditions, c. r/., improper feeding, it becomes 
pathogenic, its pathogeny being due to irritating substances in its 
{»rr»t<»plasni, as hits l>een proved by Pfeiffer, Kolle, Lidller, and Abel. 

Lehrb. d. Kinderkrank.," Bt-rlin, 1896, ote Auf.. S. 775. 
'CV»nf. Vaiiphan, Trnni>. Amer. Fed. Soc., 1890, p. 109, and Bapinskv, lor. n't., 
<. 782. 



374 ACUTE DISOBDERS OF GASTRO-INTESTINAL SYSTEM. 



II 



The acid fermentation in the intestines then becomes 
causes an intestinal catarrh, and we have the three factors, which, 
according to Marfan, favor the invasion of the general system by 
this organism : (a) injury to the intestinal mucous membrane, (6) 
dimunition of the natural alkalinity of the body fluids, one of the 
natural defences against bacteria, and (c) increase in the virulence of 
the microbe. 

Microscopic examination of the stools, careful study of cultures of 
the colon bacillus, of its virulence and its serum reaction, fail to ex- 
plain its role in the gastro-enterides of nurslings, nor can any 
special symptom or special group of symptoms be attributed to its 
action. Its part in these affections is the more difficult to explain 
on account of its frequent association with other micro-organisms. 

Its ubiquitous nature is well known, but whenever found, as is so 
common, in various parts of the body, it is almost invariably under 
conditions preceded or accompanied by intestinal trouble. Thus the 
organism is found in the bones of rachitic children, though rarely in 
pure culture, the streptococcus, the b. pyocyaneus and the staphy- 
lococcus usually being associated wath it. Cultures from the bones 
of non-rachitic children are generally sterile. The frequent occurrence 
of intestinal troubles in rachitis is well-known. The organism also 
frequently invades and causes inflammation in the appendix, bile- 
ducts, kidneys, bladder, and sometimes the urethra. McFarland 
states that it has also been met wdth in puerperal fever, Winckel's 
disease of the new-born, endocarditis, meningitis, broncho-pneumonia, 
pleuritis, and chronic tonsillitis. While it cannot be conclusively . . 
proved that the colon bacillus plays the principal part in these in- f I 
fections, it undoubtedly does play an important part. It has been 
maintained that most of the summer diarrhoeas of infancy and cholera 
infantum are due to the colon bacillus, but here again other micro- 
organisms frequently found in the stools undoubtedly play some part 
in causation, either directly through their own pathogenic action on 
the patient, or by enhancing that of the colon bacillus. 

The bacillus lactis aerogenes Welch regards as one of the colon 
group. It is " characterized chiefly by its plumper form, its more 
energetic gas-production, its rapid coagulation of milk and its denser 
growth in cultures. ^^ (Mallory and Wright.) It is found most 
abundantly in the upper part of the small intestine. 

The streptococcus is found in two varieties as described by Esche- 
rich : the S. brevis and the S. gracilis. A third, the S. pyogenes vul- 1 1 
garis, has also been described. The S. brevis has been found in the 
stools of nurslings, the gracilis in the meconium. In addition to 
these, Escherich has described a special organism which he calls the 
enteritis streptococcus. He has observed it in the sediment of cow's 
milk, and only in bottle-fed babies. It is found most abundantly at 



ACUTE SUMMEE BIABBHCEA. 375 

the end of the ileum ami at the beo:innin2: of the laro^e intestine. 
Escherich believes three clitierent elinieal pictures may be attributed 
to this variety of the streptococcus: (1) benign, (2) toxic, (3) in- 
fectious, the last being the most serious and showing the microbe in 
cultures from the blood and urine. Its specific action however ciin- 
not yet be regarded as proved. 

The enteritis streptococcus has been found in the lungs apparently 
causing broncho-pneumonia, in one case of purulent pleurisy, in the 
viscera where it is often associated with the b. coli, also in the kidney 
and spleen with the b. lactis aerogenes. 

The staph i/!ococcus pi/oqcnrx a/bus is often found in the first few 
drops of mother's milk, gaining access to the nipple from the neigh- 
boring skin, and under normal conditions is non-virulent. In mas- 
titis, however, it becomes virulent and causes gastro-enteritis in the 
nui-sling. 

The bacillus pi/oci/aneus is a rare inhabitant of the intestines under 
normal conditions. It occurs under pathological conditions, however, 
and the clinical symptoms associated with it are severe. It is not 
found in milk, and probably gains access to the intestinal tract from 
the hands of hospital attendants, and also from the pus of an otitis 
or rhinitis, in which it often occurs. Welch states that it is often 
found in diarrhoea and dysenteric discharges, and that it may cause 
ha?morrhagic and necrotic enteritis.] 

The majority of cases of acute summer diarrhoea are examples of 
acute gastro-enteritis, but in those most acute cases designated by 
the term cholera infantum death may ensue at an early stage of the 
morbid process. In such cases the intestines contain only a little 
opalescent or creamy mucus. The mucous membrane is hyperaemic 
in patches, and even in cases of only a few hours' duration, there is 
denudation of the epithelium both in the stomach and intestines.^ 
The solitary' and agminated glands and the mesenteric glands are 
enlarged. There is fatty degeneration of the liver cells, and nephri- 
tis, parenchymatous and glomerular, which may be intense even in 
cases of very short duration. The lungs show areas of collapse with 
commencing pneumonia. The blood may be inspissated and coagu- 
late imperfectly, but a consideration of tlie morbid anatomy would 
alone !)e sufficient to j^rove that the symptoms are due to general 
toxa?mia, and cannot be attril)utcd, as was formerly the custom, to 
the mere draining away of fluid through the intestines. In the most 
acute cases, indeed, and those most rapidly fatal, there may be very 
little diarrluea. 

In a well-marked case the symptoms run a rapid course. The 
infant or young child, who has previously been in good health or has 

' Klein, Dinrrhrri arul Diphtheria, Supplement to Report of Medical Officer, L. G. B., 
London, 1889 (C— 56:58), pp. 14, 78. 



376 ACUTE DISORDERS OF GASTRO-INTESTINAL SYSTE3L 

suffered for a few days from malaise and slight dyspeptic symptoms, is 
seized with severe vomiting and diarrhoea. Any food Avhich it may be 
induced to swallow is rejected almost immediately. The stools, which 
may or may not be numerous, are at first yellow, and contain the 
remains of food. Soon they become quite fluid, and of a brown 
color. The color grows quickly less deep and the motions more 
transparent, until finally they consist of a colorless, slightly opales- 
cent liquid, which does not stain the napkins. The temperature is 
generally raised, and is often very high — 105° F., and even 107° 
F. The child is restless, changing its attitude constantly, and kick- 
ing. When at rest it lies with its legs drawn up. It looks ex- 
tremely ill ; the face is flushed ; the skin of the abdomen, which 
may be slightly distended, can be pinched up into folds — " like 
linen,'' as has been said. After a short time, usually a few hours, 
collapse sets in ; the temperature falls to the normal, or below (97° 
or 96° F.) ; the extremities are cold; the face is pale and drawn. 
The eyes — sunken, half open, and motionless — are surrounded by 
dark rings ; the lips and the ears are cyanotic. The abdomen is re- 
tracted ; the skin retracted over it. The fontanelle is collapsed, the 
tongue dry, the breath cold, and the respiration slow or irregular 
and labored. The pulse is small and rapid, often imperceptible at 
the wrist ; the heart's action feeble. Diarrhoea and vomiting cease, 
or are very rare, and the child lies in a condition of the most extreme 
apathy — generally on its back with the legs extended, motionless but 
for the irregular, shallow respiration. Death may, and when collapse 
is well developed does usually, ensue at this stage. On the other 
hand, the symptoms of collapse may be much less severe, and give 
way more or less rapidly to those of reaction, with secondary fever, 
in which the temperature presents a morning fall and evening rise. 
The child remains in a condition of hebetude, is with difficulty roused, 
or, if beyond infancy, suffers from low muttering delirium. The 
face has a dusky flush ; the eyes are suffused ; the tongue dry, coated, 
and tremulous. Diarrhoea is not usually a prominent symptom, but 
everything taken by the mouth tends to excite vomiting. In other 
cases, and these form, perhaps, the majority, reaction is never 
properly established, and the child remains in a condition of collapse 
for several days. A sudden rise of temperature usually precedes a 
fatal termination. 

If the child recover it is liable to suffer further attacks, acute or 
subacute, which are often determined by a chill. ■! 

As complications of gastro-enteritis, bronchitis, broncho-pneumonia 
(generally basal), and secondary nephritis may be enumerated. In 
infants convulsions are not infrequent, and, according to Jacobi, are 
in many cases due to nephritis. Irritated by the frequent stools, the 
buttocks and perineum become inflamed. Intertrigo, impetigo, and 



I 



ACUTE SUMMER DIARRHCEA. Zll 



pustular eczema are produced, and, owing to want of care, extend 
often to the thighs, back, and abdomen, and even to the upper limbs, 
face, and scalp. 

[Prophylaxis. — We may do much to prevent the development of 
intestinal trouble or to prevent its furtlier progress once developed. 
The child's general condition should be kept as good as possible by 
attention to his diet and general hygiene. Detailed referen^o to the 
management of the diet, in both breast-fed and artiticially-fed infants 
has already been made and is pertinent here. (Appendix to Chapter 
IV.) Great care should also be paid, especially in summer, to the 
diet during the second and third years of life. If living in the city, 
the milk supply should be rigidly overlooked. Much good has been 
done in this direction in Boston, Xew York, and Chiciigo by the 
establishment of " milk funds," by means of which a supply of pure 
milk is insured Xo the children of the poor at a minimum expense. 

Almost equally important with the diet are the general hygiene 
and personal cleanliness of the child. Abundance of pure fresh air 
is essential to the maintenance of good health, and where removal to 
the country is impossible, parents should be urged to take their 
children as much as possible to the parks. They should also be 
directed to give the daily bath and to exercise great care in the im- 
raeiliate removal and washing of soiled diapers. 

The practice of allowing a diarrhoea during teething cannot be too 
strongly condenmed and should be relegated to the domain of ignorant 
nurses and midwives. It is but preparing the soil for invasion of 
some serious form of intestinal trouble.] 

In the treatment of a case of acute gastro-enteritis in an infant fed 
by hand, milk should be stopped, and the patient should be allowed 
to drink freely of water (l)oiled) cold or liot, to which some Vichy 
water may be added. As food, whey, weak veal broth, or egg-water 
may l)e given in small quantities at frequent intervals ; or, except in 
the youngest infants, barley, wheat, or oatmeal water, which, when 
projierly made, has the advantage of containing very little fermen- 
table material. 

\E(fff Water. — The white of an e^g stirred into 4 to 6 fl. oz. of 
lM»ile<i water, and sweetened with white sugar or a solution of milk- 
sugar. 

Wluji. — After the milk has been curdled with reiniet, tlie curd 
should be beaten up with a fork and the whey strained off through 
muslin. Wldte Wine Whey is made by adding 2 fl. oz. of sherry to 
half a pint f»f milk just at the boiling ]>oint. The mixture is then 
boiled for two minutes, and afterwards alh)wed to cool in a basin. 
The whey may be jKjured off, or strained off as directed above. Ap- 
|X'ndix.] 

When vomiting is an early and prominent symptom, tlie attack 



378 ACUTE DISORDERS OF OASTRO-INTESTINAL SYSTEM. 

may sometimes be cut short by washing out the stomach with boiled 
water, at 98° F., to which resorcin (1 in 1,000) or boric acid (| per 
cent.) may be added. Before withdrawing the tube, castor oil (3J) 
may be introduced into the stomach. If vomiting recurs, the wash- 
ing may be repeated, and, in an infant of nine months, tincture of 
opium 1TLj or solution of cocaine (5 per cent.) TTLij-iij left in the 
stomach. If the stomach be not washed out, the treatment should 
be commenced by a dose of castor oil or, perhaps better, of calomel 
(gr. J-J) every two or three hours to four doses. If diarrhoea be 
present from an early stage, castor oil or calomel should equally be 
given to clear the intestines, and the attack may subside. If, how- 
ever, the stools continue to be watery and foul-smelling, an antiseptic, 
such as naphthalin or salol, will be preferable ; the latter, which is 
resolved into phenol and salicylic acid in the upper part of the small 
intestine, is perhaps the more useful in the early stages. Either 
drug should be given in small doses frequently repeated. If the 
stools are green, ^^like chopped spinach/' and alkaline or faintly 
acid, lactic acid (TTlj-ij in dill water) is indicated. Watery, grayish- 
brown stools may be checked in some cases by calcium phosphate 
(gr. v-viij). When the temperature remains high, with flushed face 
and distended abdomen, or if symptoms of collapse threaten, espe- 
cially if small mucous stools are passed, large clysters are indicated. 
In an infant nine to twelve months old about a pint should be 
injected slowly, preferably by means of an irrigator. As a rule, the 
clyster is retained for from half an hour to two or three hours, and 
is then evacuated along with the infective contents of the large intes- 
tine. In addition to thus removing poisonous matter, these injections 
may have considerable effect on the temperature. Thus a pint at 
85° F. may produce a very rapid fall from 103° or 104° F. to below 
normal, and at 92° F. may cause a fall of several degrees. Such 
injections must therefore be given with caution, and their effect 
watched. Unless it is desired to reduce the body temperature 
rapidly, the temperature of the enema should be 97° or 98° F. as it 
enters the rectum ; and to attain this, that of the fluid in the reser- 
voir should be 1 ° or 2 ° F. higher. The fluid may be medicated in 
various ways — with boric acid (0.5 per cent.), sodium chloride, or 
tannin (0.5 per cent.), or with lime-water (equal parts). As an 
alternative treatment, Heubner recommends small enemas of salicylic 
acid (gr. j to gj) or quinine hydrobromate (1 per cent.). In acute 
cases, or if there be severe colic, it is well to apply hot fomentations 
or a light poultice to the belly, which should afterwards be covered 
with cotton- wool or a flannel binder. 

[The treatment should be prompt and rigidly enforced, no matter 
how slight the attack. Two factors must be borne in mind : the 
original source of intestinal trouble, i, e., the food, and the condition 



ACUTE SUMMER DIARRHCEA. 379 

of the digestive tract. The infectious agent has been introduced by 
the food, which, both in the body and out of it, furnishes an excellent 
cuhure medium for the dcvek^pment of bacteria. The intestinal tract 
contains much toxic material the result of proteid decomposition, even 
in the earliest stages of the disorder, before inflammatory changes 
have been established. Obviously our measures must be directed to 
the correction o^ these two condititms, in other words, stop the food, 
clean out the intestinal tract. All food should be withheld for at 
least twenty-four hours. If the patient be breast-fed the breast must 
be relieved by use of the breast-pump. Sterilized water should be 
given freely and often. The intestinal tract should be attacked by 
mouth and rectum, laxatives being given and copious irrigation of the 
colon being performed. Calomel is by far the best intestinal laxative 
we have, and has the additional advantage of some antiseptic action. 
We prefer it, however, in doses larger than those advised by the author, 
one grain every four hours being given to a child eight months old 
until he has received three or four doses. There is little if any danger 
of salivation, as these doses take care of themselves by the free evacu- 
ations which they cause. The lower bowels should be flushed by 
high enemata of plain warm water, one, two, or three times daily. 
The technique is important and sliould l)e carried out either by the 
physician himself or by a skillful nurse. Place the child on his 
back, introduce a large rubber catheter, or small rectal tube attached 
to the tube of a fountain syringe, an inch or two within the anus and 
start the water flowing ; gradually push the catheter up into the bow- 
els, in this way the water distends the bowels and the catheter is 
easily pushed on. As much as a gallon should be used, the water 
flowing back and out alongside the catheter. 

There are few infants and children who cannot stand the starvation- 
and-evacuation process outlined above for the first twenty-four hours, 
provided this treatment can be instituted early, within the first day or 
two. The importiince of early treatment in these cases cannot be ex- 
j'-rated. Under this simple regime, the majority of cases of sum- 
1- diarrhrea in otherwise healthv and well-nourished children will 
subside in a day and the patient be as well as ever in two or three 
days. Unfortunately, however, none but the most intelligent mothers 
can l>e persuaded to ''starve" their l)abi(^s for that first twenty-four 
hours, and often we have to allow a-to-thcm '' food." To such we must 
then give a food which will cause the least possible harm in the intesti- 
nal tract. Mention of the evil effects of proteid decom}K)sition has al- 
ready V)een made. Obviously milk and all proteid-containing foods 
should be withheld. Starchy foods only may be given and we may 
use rice water or arrow-rfK>t 4 to 8 ounces three times daily. Stci'il- 
y^fA water should lie given freely l^tween feedings. 

Ihe result of the above measures carried out for twenty-four hours 



380 ACUTE DISORDERS OF GASTRO-INTESTINAL SYSTEM. 

is, as a rule, increase in the number and putridity of the stools due to 
the action of the calomel in producing free evacuation of much of the 
decomposed intestinal contents, and improvement in the nervous con- 
dition of the patient due to the checking of absorption of toxic ma- 
terial from the intestinal canal. 

The subsequent treatment consists in a gradual resumption of the 
usual diet and continued disinfection of the intestinal canal. We 
must remember that one of the results of the attack is to impair di- 
gestive power, and that hence too much work should not be thrown 
suddenly onto the digestive functions. The number of breast-feed- 
ings, started with two or three in the twenty-four hours, may be gradu- 
ally increased, the starchy food being correspondingly diminished. If 
bottle-fed, modified milk with low percentages should be prescribed. 
Especially shall we find it imperative to begin with a minimum 
amount of proteids, often as low as \Jo of this troublesome element. 
The percentages should be increased as rapidly as possible, that we 
may give the child a diet sufficiently nutritious. For medication, 
we may give after the first twenty-four hours, calomel gr. -^-^ every four 
hours, or naphthalin or salol as mentioned above. Daily irrigation or 
at least rectal enemata should be continued. The time and rapidity of 
resumption of the usual diet must of course vary with the case and 
no hard and fast rules can be laid down in this respect. We must be 
governed by the general condition of the patient, the degree of his 
nutrition and the character of the stools, especially their odor and color. 
The increased putridity of the stools during the first twenty-four 
hours usually diminishes and disappears in the next twenty-four hours. 
If the patient be in a robust condition it is wiser to withhold his pro- 
teids until the stools have lost their putrid character, as his nutrition 
can stand the limited diet for that length of time. On the other hand 
we must not subject a weak and emaciated infant to a too rigorous 
diet, but must run the risk of increased toxaemia from decomposing 
proteids in order to preserve nutrition. Such infants of course have 
less digestive power than the robust cases from whom we withhold 
proteids, but we must nevertheless take our chances, carefully regu- 
lating and modifying the diet, adapting the food to the limited diges- 
tive powers. Predigestion by peptonization is often helpful. It is in 
such cases that feeding by accurate percentages is invaluable.] 

The treatment of cholera wfantum and the most acute cases of 
summer diarrhoea must, in their earliest stage, be the same as that 
already indicated. When the characteristic stage of collapse is es- 
tablished, drugs given by the mouth have little effect, since absorp- 
tion is very slow, but small doses (gr. Jg-) of calomel may be given, 
or naphthalin or salol may still be of use owing to their local anti- 
septic action. The use of large Avarm antiseptic clysters should be 
persevered in ; they are perhaps especially indicated when the urine 



ACUTE SUMMER DIARRHCEA. 381 

is suppressed or passed in very small quantity. Hot drinks may be 
ijiven if the ehild will swallow, and, if they induee vomitino'^ need 
not be discontinued unless they appear to add to the exhaustion. 
Three or four hot baths should be given in the course of twenty-four 
houi*s, or hot paeks with or without the addition of brandy to the 
water used. In the intervals every effort should be made to keep 
the ehild warm by artificial means. As the gastro-intestinal secre- 
tions are arrested more or less completely, only such foods as whey 
and broth can be expected to be of any service. If reaction occur 
and remittent pyrexia be established, such drugs as quinine, salol, 
naphthalin, or if there be much diarrh(xni, bisnnith may be given 
with more expectation of a favorable result. High temperature may 
call for the use of cool or cold packs. 

[If we can begin treatment early enough in cases of gastro-en- 
teritis, seldom shall we have a true cholera infantum. This term, 
used loosely and indefinitely, should be applied only to those cases 
with a true choleriform diarrhoea. The onset of such intestinal in- 
fection is mrely sudden. It is almost always preceded by more or 
less digestive disturbance, generally diarrhoea of a few days' or 
weeks' duration. Such digestive disturbance but weakens the re- 
sisting power of the intestinal tract and thus prepares the way for 
an invasion of some more serious infectious agent, and cholera in- 
fantum develops. 

Here we are dealing really with a case of general systemic pois- 
oning, and we must strike at the root or source of the toxaemia and 
at the same time counteract the effects of the poison upon the heart 
and the nervous system. The first object we strive to attain by im- 
mediate evacuation of the stomach and intestinal tract by stomach 
washing and high irrigation ; cathartics are of but little value 
as they are apt to aggravate the vomiting, their absorption is 
uncertain and thus valuable time is lost. For the second object, 
morphine is undoubtedly our best weapon, and the method recom- 
mended In* Holt most effective. He advises giving hypodermically, 
morphine gr. ^^^- and atropine gr. ^J-g^, to a child one year old, to be 
repeated every hour till arrest of the vomiting and purging and im- 
provement in the heart's action are attained. 

On account of the great loss of fluid by the discharges, water 
should be given freely ; by the mouth if possible, or by hypo- 
dermic or intra-venous injection. The high temperature should be 
combated by baths and ice-cap to the head, the baths being given 
every hour or two, beginning at a temperature of 100° and gradu- 
ally lowering this by the addition of ice to about 80°-85°. Stimu- 
lants must be usen:! freely, and often hypodermically ; brandy is our 
best stimulant. Food must be withheld until tlie vomiting has 
ceased or at least lessened. 



382 ACUTE BISOBDEBS OF GASTRO-INTESTINAL SYSTEM. 

The prognosis in the most severe cases of cholera infantum is 
bad, the majority terminating fatally, regardless of the treatment 
pursued. These results emphasize the necessity of prophylaxis in, 
and prompt energetic treatment of, even the slightest case of sum- 
mer diarrhcea in infancy.] 



CHAPTER XXXII. 

CHROXIC DISORDERS OF THE GASTRO-IXTESTIXAL 

SYSTEM. 

Chronic Gastro-onteritis — Dilatation of the Stomach — Infantile Atrophy — Tlie 
Hydrocephaloid Condition — Congenital Stenosis of the Pylorus — Constipation — 
Prolapsus Ani. 

Chronic gastro-enteritis is frequently a sequel of the acute form. 
The child becomes much emaciated, the abdomen is large, baggy, and 
soft, though liable to be rendered tense by flatulence. The appetite 
is capricious, sometimes ravenous ; at other times there is complete 
anorexia. Thirst is generally a distressing symptom, and is due in 
part, at least, to slight general catarrhal stomatitis, -which is present 
in many cases. The tongue is small, raw, or presents the peculiar 
form of superficial catarrh to which the term geographical tongue or 
epithelial desquamation is applied. 

Dilatation of the stomach is a common complication, especially 
in rickety children ; it is not rare in infancy, when it is very apt to 
be associated with urticaria, sometimes with convulsions. The dila- 
tation is caused by the distension of the stomach produced by the 
habitual use of starchy foods determining flatulent dyspepsia, and is 
favored by bulky meals. The chief symptoms are vomiting, com- 
mencing shortly after food and several times repeated, thirst, and 
epigastric uneasiness unrelieved by food. The abdomen is distended 
and tense, and the percussion note is very tympanitic over the left 
hypochondrium and down to, or below, the umbilicus. Similar 
physical signs are produced by dilatation of the colon, and the two 
conditions may be combined. When a certain diagnosis is necessary, 
which is rarely the case, it may be made by giving the child first one 
part and then the other of a seidlitz powder — the rapid distension 
of the stomach produced by the lilx?ration of cjirbonic acid gas 
causes a marked temporary alteration of the area of tympanites ; by 
auscultator}' percussion the note will be observed to change ver^' 
markedly when the finger passes beyond the stomach. 

When chronic gastro-enteritis is well established, and the colon has 
l»ecome more or less involved, the bowels act frequently, and the 
motions consist mainly of brrjwn mucus, often streaked with blood, 
or of gelatinous material like white of cgg^y with perhaps scraps of 

383 



384 CHRONIC DISORDERS OF G ASTRO-INTESTINAL SYSTEM. 



(I 



undigested food. The stools have not the ordinary fsecal odor, but 
are very offensive, sometimes horribly so, recalling the odor of putrid 
meat. In very many cases the stool is passed shortly after the in- 
gestion of food, the entrance of which into the stomach determines 
a rapid and often painful peristalsis. To this combination, so fre- 
quently met with, in which foul mucoid stools are passed after each 
meal, the term lienteric diarrhoea is commonly applied. The child 
is restless and fretful, but has occasional intervals of drowsiness, 
which are to be attributed in part to the loss of sleep at night, and 
in part to the absorption of toxic matters from the intestine. In 
some cases the large intestine is the part most affected. After an 
attack of gastro-enteritis, which may not have been very severe, the 
child begins to suffer from tenesmus, and passes foul mucous mo- 
tions, some of which contain small scybala. The tenesmus may be 
almost continuous, and small quantities of mucus are passed several 
times an hour. This condition is due to catarrhal inflammation of 
the sigmoid flexure and rectum. When the colon itself is the part in- 
volved the stools are less frequent, and there may even be constipa- 
tion. Then the most prominent symptom is colic. The attacks of 
colic may or may not end in an evacuation, and during their con- 
tinuance the colon may, in an emaciated child, be seen distinctly out- 
lined through the abdominal walls. These attacks of colic are often 
determined by the ingestion of food, and the child is quickly reduced 
to a condition of great exhaustion and emaciation. 

The morbid changes in the stomach and intestines vary with the 
severity and duration of the disorder. In the milder forms, though 
the stomach is almost always dilated, its mucous membrane may 
show little change to the naked eye, beyond perhaps some areas of 
congestion or pigmentation of the mucous membrane, which is cov- 
ered by a layer of tenacious mucus. In a more advanced stage the 
mucous membrane loses its elasticity, and becomes opaque, though 
in the most extreme cases the atrophy may be so great that the 
stomach walls are so thin as to be transparent. The earliest lesion 
is a glandular degeneration of the epithelial cells, and an inflamma- 
tory infiltration of round cells into the subjacent connective tissue. 
This round-celled infiltration extends later on into the muscu- 
laris mucosae, while at the same time the infiltration at first produced 
undergoes organization into fibrous tissue. This, in its contraction, 
throws the surface of the mucous membrane into irregular folds, and 
distorts or occludes the glandular tubules. At the same time the 
secreting epithelium undergoes degeneration. In the final stage 
there is extensive cirrhosis of the mucous membrane, and complete 
destruction of its glandular structures. Usually these changes do 
not affect the whole extent of the mucous membrane in a uniform 
manner, but are most advanced in the neighborhood of the pylorus. 



i\ 



DILATATIOX OF THE STOMACH. 385 

The small intestines undergo a similar process of interstitial inflam- 
mation with consequent fibrosis. The out is usually fouml collai)sed 
and nearly empty, and it is common to find in the ileum, especially 
near the ileo-cieeal valve, extensive shallow ulcers, which are usually 
loniritudinal. In the latest stage the intestinal walls are so thin as 
to be semi-transparent. The large intestine is not infrequently dis- 
tendeii with gas ; its mucous membrane shows patches of pun<?tiform 
pigmentation due to minute hanuorrhages, and in a large percentage 
of cases follicular ulceration is present.^ Interstitial inflammation 
here also leads eventually to fibrosis and thickening of all the coats of 
the colon. The gut may thus become greatly dilated and thickened. 
In some cases, in which this di/af((fion of the colon attains enormous 
proportions, the condition has originated very early in life and may 
perhaps have been due to congenital defect. Corresponding to the 
progressive deterioration of the glandular structures there is a progres- 
sive diminution of the digestive powers, and progressive increase in 
the anjemia and emaciation. Gastric digestion is much prolonged, 
BO that the stomach, instead of being empty in two hours or less, 
may still contain remnants of a meal (milk) taken five hours before." 

The tendency of the disease, except in the most extreme stage, is 
towai-ds recovery ; but the liability to recurrent attacks or exacer- 
bations is great, and in making a proc/nosis regard must be had to 
the care with which instructions as to the clothing and feeding of 
the patient are likely to be carried out. A large number of children 
who have partially recovered are carried off by whooping-cough or 
by measles, which in these patients is very apt to be complicated by 
severe mucous diarrhoea due to an exacerbation of the intestinal ca- 
tarrh. In an infant which has become much emaciated and ana?mic 
fmm gastro-enteritis, the prognosis is extremely bad. The (Uctr/uosis 
is not commonly difticult, though it may be impossible always to ex- 
clude the |>ossibility that the condition may be due to tuberculosis. 
Cases of this kind are very often spoken of as "consumption of the 
bowels " ; and the use of this term being assumed to exclude all hope of 
recovery is sometimes made an excuse for neglect. As a matter of 
fact, however, tul^erculous enteritis is very uncommon in infancy and 
childhood, and seldom occurs without the presence of symptoms or 
physical signs indicating involvement of other organs. 

In the treatment of chronic gastro-cnteritis, attention nuist be 
directed to the feeding and clothing of the child, and means must be 
taken to promote the elimination of the putrescent material in the 
intestines and to prevent decomposition by im])roving the digestive 
powers and administering antiseptic and carminative drugs. When 

In 62 per cent,, according to W. .Soltau Fen wick, to whose Report {BriL Med. 
Joum., 1896, vol. ii., p. 829) I am much indebted. 
*W. S. Fenwick, loc. cit. 
25 



386 CHRONIC DISOBDEES OF G ASTRO-INTESTINAL SYSTEM. 

the case is first seen, milk should be replaced by a diet consisting of 
Qg^ water, whey, or meat juices, to which carbohydrate foods, such as 
fine wheatmeal or oatmeal, may be added with caution. When the 
child begins to improve a milk diet may be resumed, the effect being 
carefully watched. In children who have previously had a mixed 
diet, it may sometimes be at once replaced by the exclusive use of 
milk diluted with water, or barley water. The child should wear 
woollen garments next the skin, and special care should be taken 
that the abdomen and thighs are covered, for these parts are often 
very insufficiently clad, not only in children of two or three years but 
even in those of eight or ten. The child should be placed under the 
best procurable hygienic conditions, should live in well-ventilated 
rooms, and should spend many hours a day in the open air. Treat- 
ment by drugs should be commenced by a dose of castor oil (3j) or 
calomel (gr. J at one year), followed by small doses of castor oil ("niv) 
or calomel (gr. J^ to -j^q^) twice a day. After each meal a dose of 
pepsin and hydrochloric acid, or of papaine, should be given. In in- 
fants the papaine may be added to the food, and if eructations are 
troublesome at any age, it is best to give papaine with the food, and 
a few grains of sodium carbonate in dill water shortly after the meals. 
A method which, in careful hands, is in many respects superior is 
the use of predigested milk. Convenient powders for this purpose 
are sold, and the quantity of proteids can be varied by diluting the 
milk before digestion ; while the quantity of fat can be increased, if 
desired, by the addition of cream. 

[The accurate modification of cow's milk, either at the laboratory 
or by home methods (see appendix Chapter IV.) is attended with 
excellent results in the feeding of these cases. The condition is one 
of impaired general digestive power and by prescribing accurate per- 
centages of fat, sugar, and proteids, we adapt the amount of these in- 
gredients to the diminished fat-, sugar-, and proteid- digesting powers. 
It would seem more rational to exercise what digestive powers the 
child has, diminished though they be, by making them do the limited 
amount of work of which they are capable and thus favor their de- 
velopment, than to do this work for them by attempts at predigestion. 
It is the same principle upon which we proceed in seeking to develop 
a group of impaired muscles ; we give these muscles exercise at first 
gentle and slight, gradually increasing it as the power of the muscles 
increases. 

It has been the experience of the reviser that these cases of chronic 
gastro-enteritis do better by careful and painstaking attention to the 
diet along the lines indicated above than by reliance upon '^pre- 
digestives," ^^ intestinal antiseptics '^ and " anti-dyspeptics."] 

An active extract of malt is a palatable remedy which acts well in 
many cases during convalescence. To correct the foetor of the stools 



II 



IXFAyTILE ATKOPHY, MARASMUS, ATHREPSIA. 387 

antiseptics should be given, such as naphthalin, salol, rosorcin (~;j of 
a 1 in 1,000 soUition). So long as the stools contain much nuicus, 
it is, however, advisable to continue small doses of castor oil, Avhich 
may be combined Avith resorcin, or the glycerine of carbolic acid 
(lUj-ij). If the stix^ls be frequent, small doses of tincture of opium 
(lUss-j) may in this later stage be added. Lienteric diarrluwi, after 
the preliminary administration of laxatives, should be treaUd by a 
mixture containing arsenic, strychnine, and the citrate of iron and 
ammonia, to which, if the diarrhcea persist, it may be necessary to add 
minute doses of opium. If the stools are copious, bismuth sometimes 
answers well, but its action is uncertain. Astringents are not to be 
recommended. As soon as the stools begin to lose their mucons 
character, some preparation of iron should be given, and none is 
superior to the citrate of iron and ammonia, which is well borne 
by children. It shonld be combined with tincture of belladonna 
(11Iiv-v at one year) if there be abdominal })ain or colic. At a some- 
what later stage, the syrup of the ph<>si>hate of iron is usually well 
taken, but the patient should eventually be put upon a mixture con- 
taining cod-liver oil and iron, guarded, if there be still a tendency to 
diarrhrea, by opium. When convalescence has been established, the 
patient should l)e given the benefit of sea or mountain air. 

When there is reason to suspect dilatation of the stomach atten- 
tion should Ix* given to the bulk of the meals; they should be small, 
and given at frequent intervals. Starch, and its derivatives, should 
be excluded. As a rule, improvement ensues after a few days, during 
which the child complains of being hungry. In cases of longer stand- 
ing, especially those in which the vomiting takes place many hours 
after the meal, it may be necessary to have resort to washing out the 
stomach. 

Infantile atrophy, marasmus, athrepsia are terms somewhat 
loosely applied to a condition of malnutrition in infants, which may 
be due to many different causes. In some cases the cause is to be 
found in congenital syphilis, or in tuberculosis. Others nuist be at- 
tributefl to a diet in>ufficient either in quantity or (piality ; while in 
others, and these form the large majority, the marasmus is due to 
chronic gastro-intestinal dyspepsia or catarrh. Cases will, however, 
occasionally be met with whieh cannot with any confidence be as- 
signed to any one f>f these categories, and it seems necessary to ad- 
mit that certain infants are lx)rn with defective powers of digestion 
and assimilation. After death in such cases the intestinal walls are 
very thin, but there is commonly no visible hypericmia, glandular 
swelling, hjemorrhage, or ulceration. The <'pith(lial eells are smaller 
than in health, owing to a diminished quantity of j)rotoj)lasn), and 
the number of leucocytes in the intestinal wall is small, very few 
being seen between the epithelial cells, where in health they are nu- 



388 CHRONIC DISORDERS OF GASTRO-INTESTINAL SYSTEM. 

merous. There are fewer also in the adenoid tissue.^ The condi- 
tion, however, it must be admitted, resembles closely that produced 
by starvation, and the diagnosis must be made by a process of exclu- 
sion. If this be done with due care and discrimination, it will be 
found that the number of cases of so-called simple atrophy is ex- 
tremely small. It is to be remembered that though it is rare to find 
a mother guilty of withholding deliberately the necessary quantity 
of food from her infant, examples of almost incredible ignorance 
are not infrequent. On the other hand, in the case of illegitimate 
infants '^ adopted '' for a small consideration, criminal intention may 
exist, which w^ill, of course, be concealed from the medical attendant. 
The term hydrocephaloid condition is sometimes applied to the state 
of depression and collapse into which young children who have suf- 
fered long from severe chronic gastro-enteritis, or who have experi- 
enced a severe attack of acute summer diarrhoea or cholera infantum, 
frequently sink. The patient lies in bed, usually on the back, in a 
somnolent state. The eyes are half-open, and exude a little muco- 
purulent secretion ; the pupils are large and sluggish. The face is 
sunken and the whole head, as it w^ere, shrunken, so that the anterior 
fontanelle is collapsed, and the cranial bones are in apposition or 
override each other. The belly is soft, the skin inelastic and easily 
pinched into folds which disappear only slowly ; the tongue is dry ; 
and the lips covered with sordes. The respiration is shallow. It 
may be rapid but is more often irregular, sometimes presenting a 
distinct Cheyne-Stokes type. The pulse is irregular, small, generally 
imperceptible at the wrist. The temperature is subnormal, 95° to 
97° F. The urine is scanty, and the child is indifferent to food and 
drink. The condition may deepen into coma, or the end may be 
brought about by convulsions. More often, perhaps, careful nursing 
in good hygienic surroundings leads to recovery, the respiration be- 
comes more regular, the pulse improves, urine is again excreted 
freely, the bowels begin to act, usually with abnormal frequency, and 
the child again desires food, and observes events happening about it. 
The patient should be nursed in a warm, well-ventilated room. A 
warm bath should be given at once, and the child should then be 
enveloped completely in a soft blanket, leaving only the face free, 
and either nursed by the fire or placed in a cot Avith hot-water bottles 
beside it, the Avhole covered lightly with a blanket. A diffusible 
stimulant {e. g., ammonia and ether), or a few drops of good whisky 
or brandy (TTlxx in water), or champagne should be given every hour. 
Minute doses of strychnine also seem to be of use. No milk should 
be given ; but, in its place, meat jelly or veal broth in small quan- 
tities every hour. The warm bath may be repeated four or five times 
a day. 

' Heubner, ''Penzoldt and Stintzing's Handbucli," Bd. iv. , S. 107. 



COySTIPATIOX. 38Q 

Congenital stenosis of the pylorus may bo iluo either to a sim})Ie 
narrowiiiiT <'t' the pyUu"ie orifice or to hypertrophy of either the cir- 
cuhir or longitudinal muscle fibres. The degree of stenosis varies. 
In the more pronounced cases there is a thickening due to hyper- 
trophy of the longitudinal muscle fibres, distinctly limited above and 
below the orifice. The stomach becomes dihited, and secondary 
gastritis leads to some general thickening of the stomach walls and 
to infiltration of the mucosa and subnuicosa by small cells. The 
swelling of the mucous membrane produced by this secondary gas- 
tritis still further narrows the pyloric orifice. 

The severity of the symptoms is proportionate to the degree of 
narrowing. The most characteristic are obstinate vomiting after 
ingestion of food, even when the meals are very small, and the 
passage of small constipated stools. The symptoms may not appear 
until a short time after birth, and the vomiting at first may occur 
only after large meals. Subsequently the symptoms resemble very 
closely those of chi*onic gastric catarrh, with which, as has been 
said, stenosis is usually complicated at an early stage. The dilatation 
of the stomach which ensues diminishes its digestive power, and 
favors fermentative dyspepsia. In some cases the thickening of the 
pylorus has \yeen felt as a small cylindrical tumor above the umbilicus. 
The interference with digestion involves a failure of nutrition, emaci- 
ati«»n, and progressive loss of strength. Death may ensue within a 
m«»nth in extreme cases. In the less severe life may he prolonged 
for two years at least, but for how nuich longer is an interesting 
question not yet determined. 

Treatment must be directed mainly to prevent or alleviate catarrh. 
The meals should be small, and if the infant be suckled, as is ])refer- 
al)le, special directions must be given to this effect. Pepsin or 
papaine will be of use to supplement the imperfect digestive 
powers. In hand-fed infants the milk should be predigested, and 
starchy foo<ls should be excluded ; meat juice may l)e given by the 
mouth, or preferablv by nutrient sujipository. In any case in which 
the existence of a pyloric tumor ciin l)e detected, the propriety of an 
operation with the view of dilating or excising the pylorus would 
arise for consideration. 

Constipation. 

\n infant at the breast has during the first two months f>f life 
IP 111 two to four, generally three, motions in the twenty-four hours ; 
from two to seven or eight months old, two or three motions ; at one 
year old, one or two motions. The motions are of a bright orange 
color, soft but not liquid, and stain the napkin. So long as the 
motions retain these physical characters, diminished frequency is not 



890 CHRONIC DISORDERS OF G ASTRO- INTESTINAL SYSTEM. 

a source of inconvenience, and an infant Avho passes only one sue! 
healthy motion a day should not be considered constipated. 

Constipation — that is, the passage at unduly long intervals of firmj 
pasty, or hard stools, generally altered also in color — is extremely 
common during the first two or three years of life, and is the source 
of much distress. It is to be traced, as a rule, either to error in 
diet or to a peculiar conformation of the lower bowel, but certain 
other conditions call for a brief notice. 

Retention of meconium may be due to inspissation to congenital 
stricture, or to occlusion of the intestine. The former condition is 
easily relieved by a simple enema ; but it should be remembered that 
no meconium may be passed after birth, owing to the intestine having 
been emptied either into the amniotic fluid or the maternal passages 
during difficult labor. Congenital occlusion occurs in the rectum, or 

Fig. 62. 





Semi-diagrammatic drawings to illustrate the three chief types of abnormality of the sigmoid 
flexure, which are the source of habitual constipation in infants. Fig. 61, Ascending position ; 
Fig. 62, transverse position. 

at the anus, where it may be diagnosed by physical examination, or 
in the upper part of the intestine, jejunum, duodenum, or ileum, 
when diagnosis is difficult, if not impossible. The first-named con- 
dition is due to a developmental defect ; the second, probably, to 
foetal peritonitis or enteritis. 

Symptomatic constipation accompanies (a) fever when it is at- 
tributed to arrest of secretions, and is apt to be followed by diarrhoea 
due to enteritis set up by putrid decomposition of the retained faeces ; 
(b) nervous diseases, such as meningitis, when it is believed to be 
due to defective peristalsis ; or (c) peritonitis. 

Alimentary constipation is observed in infants fed on cow's milk. 
It is characterized by the passage once a day, or once in two or three 
days, of large, pasty, firm, or hard whitish motions, which consist 
largely of undigested curd. It has been attributed to the excess of 



AXATOMICAL COSSTIPATIOX. 391 

casein, to the excess of earthy salts, to the poorness in sngar, and to 
the poorness in fats, characteristic of cow's as compared with human 
milk. To these conditions may be added, if the milk be insufficiently 
diluteil, a diminution in the quantity of water, at any rate in pro- 
portion to the total solids. It is probable that all these causes con- 
tribute, but that the last two are the most important. At any rate, 
addition of fat to the diet will often relieve the condition, l^rema- 
ture use of a starchy diet is also a cause of constipation in infancy, 
but this error, and in older children other errors of diet, whether 
the too exclusive use of cow's milk or of starchy foods, leads usually 
to a condition in which constipation alternates with diarrhoea, and is 
stx)n associated with flatulence, dilatation of the stomach and in- 
testines, and habitual distension of the abdomen. The retention of 
hardened fteces sets up catarrh of the mucous membrane of the in- 
testine. This appears at first to favor constipation by coating the 
ffecal masses with slippery 

mucus, but later, when more Fig. 63. 

intense, it determines diar- 
rhoea. The exposure of the 
surface of the abdomen to 
cold favors if it does not 
determine the production of 
this condition of consti- 
pation, with intercurrent 
attacks of diarrhoea due to 
catarrh. Many infants after 
being taken out of long 
clothes, and indeed the ma- 
jority of children down to Descending position (from Marfan after Bourcart). 

the age of three or four 

years, are insufficiently clad about the abdomen. 

Anatomical (essential) constipation is due to an excessive length 
and coiling of the sigmoid portion of the colon (see Figs. 01, 02, 63). 
The symptoms vary with the degree of the congenital defect, and are 
aggravated by those errors of diet which tend to produce constipa- 
tion. The history is generally clear ; the patient has always had 
motions at infrerpient intervals, and they have generally been passed 
with difficulty and much straining ; they have been of the consistence 
of a firm paste which does not .stain the napkins, or formed '^ like a 
grown-up j)erson's " or have l^een small, hard, rounded ma.s.ses, often 
coatcfl with mucus and, perhaps, .«^treaked with blood. The child 
has little or no pain except during defjecation, and laxatives either 
produce no effect or a single motion, which is accompanied by great 
pain and distress. The intervals Ix'tween the motions may be very 
long ; such periods as three or four days are common, and a week or 




392 CHRONIC DISOBDERS OF GASTRO-INTESTINAL SYSTEM. 

ten days not uncommon. As a rule, the child does not present other 
definite symptoms of illness, but it is commonly anaemic and ill- 
nourished, seklom fat. A tumor may be felt deep in the left iliac 
fossa, and a faecal mass may be felt by the finger in the rectum. The 
anus may be excoriated or fissured, thus accounting for the streaks 
of blood on the faeces, and in part for the pain on defaecation, which 
is often so great that the child voluntarily represses the call to pass 
a motion, and thus aggravates the condition from which it suffers. 
The violent straining during defaecation may produce prolapsus ani, 
or hernia, especially of the umbilicus. 

The remoter consequences of habitual constipation when obstinate 
are undue excitability of the nervous system, produced probably by 
absorption of products of decomposition from the alimentary canal, 
and showing itself in irritability, restlessness, broken sleep, and oc- 
casionally by convulsions. Frequently there is urticaria, which is 
liable to become complicated by impetigo, and to lead, on the but- 
tocks and about the anus and groins, to the condition commonly 
called eczema of these parts. Retention of faeces in the colon leads 
to catarrh of its mucous membrane, which will be aggravated if the 
belly is not warmly clad. The catarrh may be succeeded by 
ulcerative colitis. When extreme and of long standing, congenital 
constipation may lead to great dilatation and hypertrophy of the 
colon, ^ or to intestinal obstruction. 

Treatment. — The motions of a healthy infant are generally 
passed soon after suckling, and when there is a tendency to consti- 
pation advantage should be taken of this physiological fact. It is 
hardly necessary to insist that habit and custom have a great deal to 
do with the regularity of the act of defaecation, and a skilful nurse 
will begin the establishment of this habit as early as the fourth or 
fifth month of life by soliciting the infant to pass a motion at regular 
hours by holding it in an appropriate attitude. 

AVhen called upon to treat constipation in an infant attention 
should first be directed to the diet and clothing. The belly and 
limbs should be covered completely. If the infant is fed by hand 
starches should be eliminated, and replaced by malted foods made 
with dilute milk, to which milk-sugar or, in default, cane-sugar is 
added. If cream of good quality can be obtained it may be added 
to the milk, or given separately in a teaspoon, so that two to three 
or four drachms are taken daily. Suckling infants may be given a 
teaspoonful of sugar-water immediately before suckling, or imme- 
diately after. When a year old fine oatmeal is a useful article of diet, 
and the quantity of fatty food may be increased by giving butter 
with the oatmeal. Children a little older will often take greedily 

^ As to the connection between congenital constipation and hypertrophy of the 
colon, see an excellent article bv Marfan (Rev. des Mai de I'Enf., 1895, t. xiii., p. 
153^. 



PBOLAPSrS AM. 303 

butter, bacon fat, and even Inmps of cold mutton fat. At about tlie 
age of one year, or earlier in a robust infant, broth, made with a little 
veal or chicken and vegetables, may be given, or the potato-milk re- 
commended by Barlow (see p. 1246). Young children will also take 
oranges and other fresh fruit, if properly prepared for them, at an 
earlier age than is generally proposed. Infants and young children 
often suffer from thirst, which is relieved better by lemon water matle 
by adding fresh lemon juice to boiled water than by giving milk in any 
form. Milk should be i-egarded as a food and not as a drink. Such 
regulation of the diet, with the occasional exhibition of a small dose 
of com{X>uud liquorice powder, will generally do all that is necessary, 
and laxative and purgative drugs should as much as possible be 
avoided. When the habitual use of a laxative is thought to he de- 
sirable cascara sagrada will generally be found the least unsatisfac- 
tory. Small enemas of glycerine (3j-ij with about half the quantity 
of water) are useful in most cases of obstinate constipation with 
hard stools, and are probably the best routine treatment for cases in 
which the constipation is believed to be of the anatomical variety. 
If the sigmoid flexure, however, be full of fteces a large enema must 
be given and rejieated until the whole mass has been passed. A 
glycerine injection should then be given daily, and as a rule, after a 
few months the action of the bowels becomes more regular, and in 
time the disproportion between the sigmoid flexure and the rest of 
the large intestine ceases, with the growth of the parts, to be a 
source of discomfort. 

[The essential point in the treatment of constipation is to remem- 
ber that it is after all only a symptom and that we must seek to de- 
termine the underlying cause of the symptom. In early infancy it 
is almost a normal condition, later it is abnormal and should be cor- 
rected by treatment of the patient, not of the symptom alone. In 
nurslings it is apt to be the result of constipation in the mother and 
it is the latter, not the baby, who should be treated. Analysis of 
the breast-milk should be made. Attention to the diet in ])ottle-fed 
infiints and older children will generally correct the condition in 
these two classes of patients. Fruits are of value, and orange juice 
and prune juice may be given to an infant of a year. Older children 
may have a greater variety of fruit : baked aj)ple, apple sauce, ripe 
pears, peaches, f>r plums. Massage of the abdomen, following the 
course of the colon, often helps to overcome the habit. This should 
be practiced at a definite hour each day.] 

Prolapsus ani is a common complication of catarrhal inflamma- 
tion of the hirgc gut and of the rectum. It is most apt to occur in 
ill-nourished children, and is produced by straining at stool, or by 
straining in micturition, due either to phimosis or occasionally to 
stone in the bladder. At first there is merely a pouting of the rectal 



394 CHRONIC DISORDERS OF GASTRO-INTESTINAL SYSTEM. 

mucous membrane through the anus at each motion. This gradually 
increases, or perhaps a sudden increase is produced by more than 
usually severe straining, and a large sausage-shaped mass, which 
bleeds easily, is found protruding from the anus. In rare cases the 
prolapse is due to rectal polypus which is grasped by the sphincter 
at each motion. As a rule in prolapse the sphincter is relaxed, and the 
prolapsed gut returns spontaneously or is easily reduced by gentle 
pressure. In some cases, however, there is considerable constriction 
at the anus, and the prolapse becomes deeply congested, oozes blood 
freely, and is reduced with some difficulty. 

The rectum is invaginated through the anus, and to effect its re- 
duction it must be grasped at its lower part, and squeezed gently 
upwards. To prevent recurrence the child should be caused to use 
a seat with a small aperture when passing a motion, and the thighs 
should be tied together, the buttocks and perineum being afterwards 
well washed. If the patient is an infant the nurse should be in- 
structed to hold the thighs in contact when a motion is being passed. 
If stone in the bladder be present, or phimosis, they must be treated 
by ordinary surgical methods. Astringent injections into the rectum 
are seldom attended by more than very temporary improvement, and 
I have never found it necessary to resort to the subcutaneous injec- 
tions of ergotine and strychnine in the neighborhood of the anus 
which have been recommended by some writers. In the great ma- 
jority of cases the condition is merely a complication of ileo-colitis, 
and disappears when this is ameliorated by suitable treatment. Be- 
fore reduction the prolapsed gut should be greased with ointment of 
galls or, if there be pruritus, with carbolic acid ointment (1 in 40). 
Hamamelis also (Tllxx-gj) is a useful application. 



CHAPTER XXXIII. 
INTESTIXAL OBSTRUCTION. 

Congenital — Acquired — Symptoms — Diau:nosis — Treatment. 

Intestinal obstruction may be due to congenital defects of de- 
velopment.^ Thus the small intestine may bo narrowed at various 
points, for example in the duodenum at the point of insertion of the 
comuKMi bile and pancreatic ducts, at the point where the duodenum 
joins the jejunum, or at or a little above the ileo-ctecal valve. The 
large intestine may be narrowed by displacement of the sigmoid 
flexure (see above), by a defect of development of the colon, or by 
narrowing of the point of insertion of the colon into the sigmoid 
flexure. Finally, there may be atresia ani, or imperforate anus. 
Acquired obstruction may be due to a variety of causes, which may 
be classified according as to whether they operate from within or 
without the gut. Thus the lumen may be contracted or completely 
obstructed by impaction of faecal masses or foreign bodies, by new 
growths or by cicatricial contraction secondary to inflammation of 
the intestinal mucous membrane. Causes operating from without the 
intestine are false ligaments (bands) and adhesions, stricture due to 
protrusion through the ring formed by attachment of Meckel's di- 
verticulum to the abdominal wall or mesentery, volvulus, intussus- 
ception, knuckling of the intestines, and the pressure of a tumour. 

Of the congenital conditions imperforate anus is the most com- 
mon ; of the acquired, intussusception and the impaction of masses 
of hardened foces or collections of foreign bodies. 

The symptoms of intestinal obstruction are colic, vomiting, col- 
lapse, tympanites, and constipation. Each calls for separate consid- 
eration ; all may, and probably will, develop sooner or later ; the 
mode in which they develop may aflbrd indications as to the nature 
and seat of the obstruction. 

C'o/Zc, as a rule, comes on suddenly in the midst of perfect health, 
or after slight diarrhrea or constipation. The pain occurs in par- 
oxysms, during which the form and vermicular motions of the gut 
may be plainly seen and felt through the Jibdominal walls. The in- 
tervals between the paroxysms lessen, until at last the pain is almost 
continuous. If the obstruction be in the small intestine, the pain 
•See a paper by Monti (AUg. Wien. med. Zeit.^ 1894, Nos. 35 and 36). 

895 



396 INTESTINAL OBSTRUCTION. 

appears to start from the uavel, and to radiate towards the stomach ; 
if in the large intestine, the pain is referred to the regions occupied 
by the colon. 

Vomiting, which is generally preceded by eructations, comes on 
soon after the colic sets in, and each attack of colic may end in vom- 
iting. If the obstruction is very sudden and complete, the vomiting 
may be the first symptom, and is the more violent the higher up the 
obstruction. The vomited matters are at first, in all cases, the con- 
tents of the stomach, then glairy, bile-stained fluid, which after a 
time has an offensive odor. When the obstruction is in or below the 
middle part of the ileum the vomited matter eventually acquires a 
feculent odor, and with obstruction at or not far above the ileo-csecal 
valve, actual formed faeces may be vomited. 

Collapse is produced by the pain and vomiting. The face becomes 
pale, the eyes sunken, and there is a cold sweat on forehead and feet, 
small rapid pulse and hurried respiration. A condition of great 
mental depression almost amounting to unconsciousness ensues. At 
first the child revives a little between the attacks, but later the col- 
lapse is continuous. 

Tympanites begins soon after colic and vomiting. Speaking gen- 
erally, it is the greater and more extensive the lower down the ob- 
struction. When this is in the rectum, sigmoid flexure, or descend- 
ing colon, the distension affects first the colon, and tympanites is 
observed in the flanks and epigastrium ; later the distension of the 
abdomen becomes general. AVhen the lower part of the ileum, or 
the caecum, is the seat of obstruction, the small intestine becomes 
distended, causing tympanites in the umbilical and. hypogastric 
reo'ions. Later the increasino^ distension of the small intestine causes 
the colon to be pushed away, and the tympanites becomes general. 
AVhen the obstruction is as high as the jejunum, tympanites, if it is 
produced at all, appears late and is limited to the epigastrium ; it 
may vary in degree, diminisliing after vomiting. If in any situation 
the obstruction is incomplete, the distension is less and may diminish 
notably from time to time in connection with passage of flatus by the 
rectum. 

Constipation, which develops sooner or later in acute obstruction, 
may be preceded by one or more actions of the bowels, which are 
either spontaneous or induced by enema. When the obstruction is 
high up the stools may even be copious ; but eventually in these 
cases, and from an early stage in those in which the obstruction is 
low down, there is complete constipation, not even gas being passed. 
There may be, however, in association with the colic, severe tenesmus 
resulting in the passage of a little blood-stained or discolored mucus. 
This is particularly the case in obstruction of the colon, sigmoid 
flexure, or rectum. If the obstruction be not complete after several 



Ji 



IXTESTIXAL OBSTBUCTION. 



39: 



days of constipation and tympanites, copions, loose, fonl-smcl lino- 
motions may be passed with great relief to the tympanites and all 
the general symptoms. In partial obstrnetion of the reetnni hard 
scybala are passed with much painful tenesmus. In annular con- 
striction of the rectum, or the lower jxirt of the colon, the fieces may 
be of the thinness of a pipe stem, or flat and ribbmi-like, or small 
like sheep droppings. 

The urine is diminished in quantity when the obstruction is situated 
in the small intestine, and when very high up there may be complete 
suppression. 

Palpation of the abdomen will reveal the existence of a tumour, or 
of an area over which there is an undue fulness in cases of obstruc- 
tion by masses of impacted fi\?ces, and in intussusception it is usually 
possible to feel a tumour, more or less sausage-shaped, in the left flank, 
or perhaps more towards the middle line. In intussusception, in 
addition to the ordinary signs of acute obstruction, there is commonly 
also a good deal of tenesmus, and frequent discharge of blood-stained 
mucus from the rectum. In all cases of doubt it is imperative to 
make an examination under an anaesthetic, when, as a rule, the tumour 
of intussusception is found to be well defined. Examination by the 
rectum should be practised in all cases of obstruction in which its 
seat and nature cannot otherwise be ascertained. 



Duodenum or J^ununi. 



Lower Ileum. 



Lower Colon. 



Col ic Severe , radiating from 

navel to stomach. 

Vomiting Early, violent bile- 
stained, and later 
foul -smelling. 

t.<iiai»se Early and severe. 

Tympanites .. S 1 i k h t ; epigastric ; 

d i sap pears after 

vomiting. 

Motions May l>e copious at 

first. 
Palpation 



Urine Early complete sup- 

> pression. 



Severe, radiating from 
the ileo-caecal re- 
gion. 

With each paroxysm 
of colic ; at first 
food, finally fecu- 
lent. 

Early. 

Marked; at first 
m a i n 1 y umbilical 
and hypoga.stric re- 
gions. 

Mav be copious at 
fi'rst. 
j If due to intussusceji- 
tion, cylindrical 
tumor. 

Suppression may oc- 
1 cur late. 



Radiating pain over 
whole a 1) d o m e n 
from left Hank. 

Late, and only after 
paroxysms of colic 
as a rule. 

Late. 

Marked ; limited at 

first to the regions 

of the colon. 

Early comjdete con- 
stipation. 



L'na fleeted 



The table above, compiled from Monti, may be of use in 
arriving at a diagnf»sis of the probable seat of the obstruction 
in fjbscure cases. 

With regard to the treatment of obstruction no general rules can l)e 
laid down, owing to the great variety of lesions to which the condition 



398 INTESTINAL OBSTRUCTION. 



i\ 



may be due. It is then inadvisable to give opiates until a diagnosis 
is made, as they are apt to mask the symptoms and cause the loss of 
valuable time (see appendicular peritonitis). Purgatives should not 
be given, but the large bowel should be irrigated by copious injec- 
tions of boiled water. The stomach should be washed out, especially 
if vomiting be troublesome ; this procedure nearly always gives re- 
lief, and in some cases has been followed by disappearance of the ob- 
struction and complete recovery. Tympanites, at least, is almost 
invariably diminished by this means ; but hot fomentations, with or 
Avithout turpentine, should also be used for its relief. In intussus- 
ception the success of any treatment short of laparotomy must, to a 
large extent, depend on whether the two surfaces of the intussus- 
ceptum and intussuscipiens are or are not fixed by lymph. As the 
rate at which the lymph is effused differs very greatly in different 
cases, the duration of the case is not an infallible guide, though it is 
very improbable that the bowel will be unfolded except in a very 
early stage, since the intussusceptum soon becomes much swollen 
from obstruction to the circulation in its Avails. Occasionally in- 
version, AAdth massage of the tumour through the abdominal Avails, has 
been successful ; but such manipulations must be very gently per- 
formed. Distension Avith fluid (AA^arm Avater or oil) or gas (from a 
gasogene or siphon) has succeeded. The quantity of fluid required 
AA'ill be from one to two pints. It must be injected slowly, and 
should be not cooler than 85° F. Care should be taken to see that 
the tube introduced into the rectum is passed Avithout injury to the 
rectal AA^all, for the intestine has more than once been perforated and 
the fluid thrown into the peritoneal caA-ity. Failing reduction by 
these means, immediate laparotomy offers the best hope of recovery. 
If the reduction does occur, the patient should be kept at rest and 
giA^en small doses of opium, Avhich should be combined with bella- 
donna. 



CHAPTER XXXIV. 
IXTESTIXAL PARASITES. 

Taenia Solium — Tsenia Mediocanellata — Bothriocephalus Latus — Tj^nia Canina; 
Symptoms of Tape-worm; Prophylaxis; Treatment — Ascaris Lnmbricnidcs; 
Treatment — Oxyuris Vermicularis ; Treatment. 

Infestation by animal parasites is comparatively rare in infancy, 
but becomes progressively more common as childhood advances. 

Taeniae. — Tania solium and Tcvnia mediocanellata are not uncom- 
mon in children over two years old, but are much less often met 
with inuler that age. 

Taenia solium is a parasite of pigs. The fertilized egg swallowed 
by this animal undergoes development, jienctrates the mucous mem- 
brane, and travei'ses the tissues until it reaches a muscle, generally 
that of the tongue, neck, or shoulder, where it becomes fixed in the 
intermuscular tissue, and there passes its cystic stage. It is hence 
known as the cysticercus cclhilosa\ The cysts are about the size of a 
pea. In its cystic stage the worm may be a parasite of man also, 
sometimes in great numl>ers. It occurs in the intermuscular con- 
ne-ctive tissue, in the subcutaneous tissue, the eye, and the brain, 
where the symptoms it produces are those of cerebral tumor. If the 
living cysticercus reaches the human stomach with uncooked or in- 
sufficiently cooked pork, it undergoes development into the tmnia 
mliuia. The scolex consists of two parts — the head and neck. The 
head is globular, and has at the summit a rostrum, or proboscis, sur- 
rounded by four suckers. The rostrum bears two concentric cro\vns 
of hooks. The neck is thin and has transverse stride towards the 
lower extremity. As the animal grows, a series of segments form. 
They are at first broader tlian long, but become longer as they grow, 
until finally they are twice as long as they are broad. The segments 
are hermaphrodite, but after the fertilization of the ova in the uterus 
all the other organs atrophy, so that the ripe segment contains little 
more than the uterus distended by eggs. The genital sinus opens 
at the side by a }K)re, which is on different sides on alternate seg- 
ments. The eggs are round and about yj^ inch in diameter. The 
ripe segment becomes detached, and it is by the observation of one 
or more such segments in the st<^K)ls that the existence of the para- 
site in the intestines is first discovered by the patient. J>efbre this 

399 



400 INTESTINAL PARASITES. 

occurs the whole worm may have attained a great length, forming 
a long riband, whence its popular name tape-worm. The eggs con- 
tained in feces reach the pig either in its food or by water. In 
cases of cysticercus in the human species, the eggs have probably 
entered the stomach Avith impure water. The Tcenia solium is the 
most common tape-worm of man, and is not infrequent in children. 

The intermediate host of Taenia mediocanellata is the ox. The 
egg, which is oval, reaches the animal either through food or water 
contaminated by human excrement, and becomes encysted in the 
muscles and viscera. It is killed by a temperature of 118° F., and 
can thus only reach tlie human intestine alive when beef is eaten raw 
or very imperfectly cooked. It grows there in the same way as the 
tcenia solium^ and may attain an enormous length. The head is flat- 
tened above, square rather than globular, and larger than that of 
tcenia solium; it has four suckers, but no hooks. The segments 
when ripe are two or three times as long as they are broad ; they are 
easily detached, and are passed frequently in chains of three or four. 
The genital pore has the same position as in tcenia solium. This 
worm is said to be common in Abyssinia, and is attributed to the 
eating of raw meat. The practice of giving grated raw meat in 
infantile diarrhoea and in phthisis is believed to be increasing its 
prevalence in Europe. According to Osier, it is the commonest 
tape-worm in America. 

Bothriocephalus latus. — The eggs of this w^orm are elliptical, pos- 
sess an operculum, and are larger than those of the tsenise. When 
free in water the egg develops slowly into a motile embryo, which 
can survive in this stage for some days or weeks. Certain fresh 
water fishes, especially the pike, serve as intermediate hosts, the both- 
riocephalus being found in the peritoneum and muscles. The worm, 
fully developed in the human intestine, has a relatively large almond- 
shaped head, without a rostrum or suckers, but with two lateral de- 
pressions. The neck is thick and flat. The fully developed seg- 
ments are very large, and may be an inch long and nearly as broad. 
The genital pore is in the middle line and towards the front, but the 
eggs are extruded by another orifice farther back. This worm is 
very common in fishing villages in the Baltic, but is met with occa- 
sionally elsewhere. 

Taenia canina ( cucumerina ) is a parasite of dogs. It has been 
met with occasionally in children, hardly ever in adults. It is a 
small, short worm ; the head has a rostrum bearing four rows of 
hooks. The intermediate host is the dog-louse ( trichodectes canis ), 
and it occurs also, it is said, in fleas on dogs. The dog becomes in- 
fected by biting the itching parts and so swallowing the lice which 
contain the cysticerci. Children probably become infested by hand- 
ling and kissing dogs and cats, and being " kissed ^^ — i. e., licked — 



T^NIJE. -iOl 

by dogs. Tivnia elliptica, a parasite of eats, is probably identical. 

Taenia nana is a small ta])e-worin very rarely met with. Bilharz 
found a large number in the duodenum of a boy in Egypt. The 
head has a rostriun carrying a circle of hooks and four suckers. 

The si/mptoms produced by the presence of tape-worms ( t. solium 
and t. mediocancUafa) are very indetinite. Dyspepsia, nausea, abdom- 
inal discomfort, diarrhoea, pruritus ani, and itching of the nose may 
be present ; but these are common symptoms, and cannot with cer- 
tainty be attributed to the presence of the worm or worms. In 
many cases no complaint of any kind is made until after the exist- 
ence of the ta?nia is made known by the passage of the segments, 
either with the stools or separately. The children are generally 
thin and anj^mic, and bothriocephalus can produce severe ansemia 
which may even be fatal. In a few cases jaundice has been observed 
as a complication, and has been attril^uted to the head of the worm 
being implanted near the orifice of the bile duct. Complaint is often 
made of headache, and vertigo and a large number of nervous symp- 
toms have been attributed to the presence of tape-worm. Among 
these the most important are epileptic attacks, characterized by a 
long aura, a long convulsive stage (ten to fifteen minutes), and by a 
subsecpient period of drowsiness or unconsciousness, which is also 
long. Such cases are very rare, and the connection between the 
fits and the presence of tieniae is not well established. The same re- 
marks apply with even greater force to chorea, mania, strabismus, 
amaurosis, and limitation of the visual fields, which, it has been as- 
serted, may be produced by tape-worms. 

The diagnosis depends entirely on the discovery of the segments 
passed from the bowel. 

The prophylaxis is important. ]\Ieasly pork or beef should not be 
use<l, though thorough cooking will kill the parasite. The use of 
grated raw beef may be a source of infection if the meat be not 
carefully selected, but the risk may be avoided by using chicken for 
this pur|X)se. The segments, when passed, should be burnt. 

In the treatment of taenia the patient should have a mild saline 
laxative, and should always take a very light diet — broths and soups, 
with little milk for two days, or at least for one day before the vermi- 
fuge is given. If the child has mucous diarrhoea, this should first 
be treated. The most trustworthy remedy is male fern. A child of 
ten may take 3J of the licjuid extract made up with peppermint 
water or other aromatic. It is advisable to give as large a dose 
as appears permissible on the first occasion, as it is l)elieved that the 
drug on subsecpient administrations has less effect than on the first. 
It should l>e given the first thing in the morning, fasting, and fol- 
lowed in about two hours by a full dose (half an ounce) of castor 
oil. In weakly children the dose of male fern may be smaller, but 
26 



402 INTESTINAL PARASITES. 

very small doses are practically useless. In the more robust not 
only should the dose of male fern be larger but castor oil may be re- 
placed by a calomel and jalap powder. Pomegranate root is also an 
efficient remedy. Half an ounce of the bark is macerated in two or 
three ounces of water and evaporated to an ounce, which may be 
taken by a child of five in three doses during the morning. Its alka- 
loid pelletierine is not to be recommended for young children, but at 
the age of ten or twelve either the sulphate or tannate may be given 
(gr. ij fasting). Turpentine has often been used with effect, with or 
without the addition of kamala. Osier gives a combination of pome- 
granate, pumpkin seeds, and male fern. 

Ascaris lumbricoides, popularly called the round worm, is a cylin- 
drical worm of a creamy or greyish red color. The female, which 
is four or five times as numerous as the male, measures some 8 to 12 
inches, and is about the thickness of an ordinary lead pencil. Both 
extremities are pointed, the anterior more than the posterior. In the 
male, which is of about half the size of the female, the posterior ex- 
tremity is curved into a hook. The body is marked by transverse 
lines. The mouth is at the anterior extremity, star-shaped, and pro- 
vided with three chitinous nodules. The eggs, which are very nume- 
rous, are elliptical, of a brown color, measure .075 mm. by .058 
mm., and have a double shell with an albuminous coating. They 
may be contained in the faeces in large numbers, and can withstand 
drying and freezing. In water they develop into embryos. There 
is no intermediate host, but the human intestine is infested directly 
by the eggs, which are no doubt carried by water, in which they can 
survive for some time. 

This parasite is extremely common in children in temperate 
climates, but is still more frequent in tropical countries. It is more 
common in the country than in towns, and is said to be especially 
frequent in idiots and in children who have acquired the habit of 
eating dirt. It does not occur in infants nourished exclusively at 
the breast, and it is rare even in those fed artificially. 

When the intestines are infested they usually contain more than 
one individual. The most common habitat is the lower part of the 
small intestine. The development of the worm is probably very 
rapid after it has become established in the intestine. When full 
grown it seeks to escape. As a rule, it finds exit by the anus, either 
with the stool or independently, being found not infrequently curled 
up in the bed, having escaped while the child slept. It may occur 
also in the colon, the duodenum, the stomach, and not very infre- 
quently escapes by the mouth, either with or without vomiting. It 
may find its way into the naso-pharynx, and may thence be extracted 
by the child. In rare cases it has been known to enter the Eus- 
tachian canal, and appear at the auditory meatus ; it has become 



TjENIJE. 403 

impacted in the larvnx, causing sudden death, and has reached a 
bronchus and led to ganorene of the hnios. The worm may also 
force its way into the bide ducts, causing jaundice, dilatation of the 
bile ducts, and suppuration. Osier mentions a case in which the 
common duct and the main branches thoughout the liver were 
enormously distended and packed with numerous worms. In ulcera- 
tion of the intestine in enteric fever or tuberculosis, the worm may 
pass through into the peritoneum ; but the assertion that it can pass 
through the healthy intestinal wall, and so lead to peritoneal abscess, 
cannot be accepted. It has also found its way into the bladder. 
AVhen very numerous the worms may l)ecome rolled together, form- 
ing large masses which have caused intestinal obstruction ; other- 
wise the ascaris does not produce any lesion of the intestine. Ab- 
scesses containing one or more worms have been met with in the 
inguinal and umbilical regions. 

The number of symptoms which have been attributed to the pres- 
ence of round worms in the intestine is legion. While it is certain 
on the one hand that even an immense number of ascarides may be 
present — Massini has recorded the case of a girl aged three years, 
who during less than two months ]xissed 8,000 — without any symp- 
toms whatever, yet it will be found that children infected with these 
worms often present various signs of ill-health — restlessness, colic, 
picking at the nose, anal irritation, pallor, and dark rings round the 
eyes. Further, in neurotic children various nervous symptoms may 
be de}x?ndent on the presence of round worms, and disa])])ear when 
they have been expelled. Headache, and choreiform movements, 
and in younger children convulsions and symptoms suggesting men- 
ingitis (retraction of the head, vomiting, loss of consciousness, and 
dilatation of the pupils) may disappear after one or more round 
worms have been passed. AVhen numerous, marked anaemia may be 
produced, and Demme^ has recorded cases in which the symptoms 
resembled those of pernicious anaemia. In one of these cases the 
number of red blood-corpuscles was 2,450,000, the proportion of 
white to red corpuscles 1 : 90, and the haemoglobin 40 per cent. After 
the passage of a large number of round worms the number of red 
red blood-coq^uscles rose in a few weeks to 4,100,000 the haemo- 
globin to 70 per cent, and the proportion of white to red corpuscles 
fell to 1: IGO. 

The diagnosis must rest on the passage of a round worm, or on the 
discovery of its eggs in the faeces. In doubtful cases a vermifuge 
should he administered. 

In the treatment the most reliable drug is santonin. It causes the 
worm to become detached, and should be combined with small doses 
'^'f calomel, or followed by castor oil or a saline laxative to ensure 
'Jahrb.f. Kinderhlhl, Bd. xxxv., S. 276. 



404 INTESTINAL PARASITES. 

expulsion. The dose for a child of three shoidd be 1 to IJ grains. 
This should be given at night, and the laxative in the morning. If 
the daily dose be divided into three, given at intervals of one to two 
hours, beginning in the early morning, the effect is perhaps better. 
The main objection to its use is that it sometimes produces nausea, 
yellow vision, urticaria, or a scarlatiniform erythema, and some pain 
on micturition. A very large dose may produce much more serious 
symptoms ; vomiting, dilatation of the pupil, dyspnoea and cyanosis, 
convulsions, epistaxis, and hsemoglobinuria. The child may become 
collapsed, and death has been known to occur. These symptoms, 
which have been observed usually after rather indiscriminate admin- 
istration of ^^ worm tablets '' by the parents, are possibly due to some 
impurity in the drug ; but it is advisable to begin with small doses, 
and after the third morning to stop the drug for a week or ten days, 
then to give a dose of calomel with jalap or jalapine, and resume the 
santonin if the worm or its egg are found in the stools. Oil of tur- 
pentine is also an effectual remedy. The dose should be 5J for a 
child of ten, prescribed with mucilage of tragacanth in infusion of 
senna. 

Oxyuris vermicularis. — The common thread worm or seat worm 
inhabits the colon and rectum, but conjugation takes place probably 
in the lower part of the ileum. The female is about J inch long (9 
to 10 mm.). It occurs in much larger numbers than the male, which 
is about half its length. The end of the tail in the female is sharp, 
in the male blunt and furnished with a spiculum. The eggs, which 
are 3 to 5 11 in diameter, are swallowed with water, salads, etc., but re- 
infection is possible, the eggs being carried from the anus to the mouth 
by the fingers. Catarrh of the lower bowel favors the establishment 
of the parasite. The parasites wander at night to the anus, by 
which they escape, causing great itching and irritation. Children, 
especially between the ages of two and five, are particularly prone 
to be the hosts of these worms, which may, however, be present at 
any age. 

The diagnosis may be made by the observation of the worm. It 
may be found in the folds of the anus, or its eggs may be found in 
the faeces. It has occasionally been passed through the mouth. 

The symptoms are mainly those of local irritation, intense 
itching and burning, coming on usually at night, and waking the 
child up. It scratches the anal region and rubs its thighs together; 
in this way is produced an eczematous condition about the anus, 
and intertrigo in the inguinal region, where, indeed, the worm may 
be found occasionally. In girls the parasite may wander into the 
genital j^assages, causing great itching and irritation. In both sexes, 
but especially in the female, it is believed to predispose to nocturnal 
incontinence of urine. The effect of the presence of these parasites 



OXYUEIS VERMICULARIS. ^05 

on the general health may bo vorv injnrious, owing to loss of sleep 
and constant irritation. The child is thns predisposed to nervons 
disorders, thongh it is donbttul whether either convnlsions or chorea 
can be directly attributed to their presence. 

Treatment must be directed : (1) To the relief of the itching 
by carbi^lic, belladonna, or weak white precipitate ointments made 
with vaseline, and by the injection of a small quantity of olive oil 
(3j-ij) into the rectum. (2) To clearing the rectum and sigmoid of 
the worms, for which purpose larger injections of common salt (3 j 
in O ss of cold water), infusion of cpiassia, carbolic acid solntion (1 
in 100), vinegar and water (equal i)arts), or turpentine (3J-ij mixed 
thoroughly with soapy water) may be used once a day. (3) To de- 
stroying the parasites in the ileum and upper colon, wdiere probably 
is their breeding-place. A laxative should be given, either a saline, 
or the old-fasliioned compound rhubarb, or compound liquorice 
powder, followed by vermifuges. Santonin is often used for this 
purpose, but a continuous action is to be sought, and it is not de- 
sirable to continue the use of this drug for more than three or four 
days. Very good results may be obtained with naphtlialin, given 
four or five times a day for two days after the bowels have been 
well opened, then suspended for a week, and repeated if necessary 
for two days more. A third and a fourth course may be necessary. 
The dose for a child of two isgr. ij-iij in powder with sugar. Xaph- 
thaline is soluble in fats, and they should be excluded from the diet 
during the treatment, as the solution not only interferes with the 
action on the oxyuris but may lead to symptoms of general poison- 
ing. (4) To improve the condition of the lower bowel, which is 
usually affected by catarrh. (5) To prevent reinfection. The child's 
nx>ni and all clothing, bedding and toys should l)e scrubbed and dis- 
infected. The finger-nails should be kept short and well washed. 
Frequent bathing and change of linen are advisable. 



CHAPTER XXXV. 
HYDATID DISEASE. 

Taenia Echinococcus — Geographical Distribution — Hydatid of the Liver ; of the 
Lung ; of the Heart ; Intracranial ; of the Kidney and Spleen. 

Taenia echinococcus is a very minute tape-worm which infests 
the dog. It consists of a head and three segments, only the last of 
which is mature. The whole measures about ^- inch in length. The 
ripe segment may contain as many as 5,000 eggs, which are ovoid, 
about 0.01 mm. in long diameter and provided with a shell. Swal- 
lowed with water, or on herbs, by the ox, pig, sheep, or man the 
shell is dissolved, and the embryo, which has six hooks, burrows 
through the walls of the gastro-intestinal canal and may reach the 
peritoneal cavity or the muscles. It may enter a blood-vessel and 
be then carried to various organs, especially by the portal blood to 
the liver. Once arrested in an internal organ the embryo passes 
into the cystic stage. The peculiar characteristic of this parasite, 
and that which gives it its clinical importance, is that instead of re- 
maining single, and in size small, it multiplies by a process of in- 
ternal gemmation, so that the much distended primary cyst may 
eventually contain a number of included or daughter cysts, and these 
daughter cysts, again, a further set of grand -daughter cysts. From 
the lining membrane of the cysts buds arise and develop into scolices, 
which are, in fact, the heads of tcenia echinococcus. When swallowed 
by the dog they develop into that taenia and attain sexual maturity. 
The budding begins about five months after the embryo has become 
fixed. The cyst can continue to live and to grow for years. If the 
parasite die, the contents of the cysts undergo inspissation, and are 
converted into a granular, putty-like material. The fluid contained 
in a living hydatid is clear and colorless. It contains no albumen 
recognizable by ordinary clinical tests, but about 0.5 per cent, of 
chloride of sodium, traces of succinates and sugar, and a toxic body, 
probably of the nature of an albumose. The hydatid cyst becomes 
surrounded except in the lungs by a capsule of fibrous tissue derived 
from the organ in which it is imbedded. Suppuration may occur 
within this cavity, and may lead to rupture and to grave symptoms. 
Rupture may also occur without suppuration, either spontaneously 
or as the consequence of a blow. 

406 



TAENIA ECHINOCOCCUS. 407 

The geographical distribution is peculiar. It is certainly very un- 
common in Great Britain and on the continent of Europe, especially 
in chihlren, and appears to be unknown among- native-born Ameri- 
cans. In Austi-alia, however, it is very connnon, and children seem 
to suiFer, at least, as much as adults. In the Children's Hospital, 
Sydney, X. S. AV., 1 case out of 173 admitted suffered from hydatid 
(Stirling). This is almost the same proportion as that for all hos- 
pital patients in Xew South Males, which, according to Stirling,^ 
is 1 to 175. Thomas found that of the fatal cases which he collected- 
7.G per cent, occurred under the age often years, and 10.7 per cent, 
between the ages of ten and twenty. As he points out, a suckling 
child is very unlikely to receive infection, and the youngest patient 
that he had met with was a child aged two years and one month 
upon whom he operated for hydatid of the liver. 

As in adults, the most usual site is the liver. Of 120 cases of 
hepatic hydatid collected by Murchison, and in which the age is 
stated,^ 12 were in children under ten years, and 16 between ten 
and twenty years. The symptoms and physical signs are those of a 
slowly growing tumor of the liver. It is usually painless, though 
not always, for complaint of aching pain in the liver is made not 
infrequently before definite swelling can be detected. It is elastic 
or fluctuating, and may afford hydatid fremitus. The physical signs 
of hydatid of the convexity resemble those of hydatid of the base of 
the lung, and it may be impossible to distinguish between these two 
conditions. Further, in both cases the physical signs are much the 
same as those of a limited effusion into the pleural cavity. This 
point is discussed below. Hydatid, moreover, may produce pleurisy. 
Hydatid of the lower surface of the liver may be mistaken for hy- 
dronephrosis, but it is usually more superficial than a renal tumor, 
and pushes down the colon in front of it. Frequently it can be felt 
as a rounded swelling giving an irregular outline to the lower edge 
of the liver. It moves with respiration, and on percussion is con- 
tinuous with the liver dulness. Hydatid of the liver may rupture 
into the stomach or intestines, the bronchial tubes, the pleural cav- 
ity, or the peritoneum, through the abdominal walls, or into the 
urinary passages, the order of frequency being that here given. Of 
these accidents, rupture into the intestine appears to be most favor- 
able to the patient. Rupture into the lungs may cause sudden 
death from suffocation or, if that is escaped, long and exhausting 
illness with the symptoms of basic cavity or pulmonary gangrene. 
Rupture into the pleural cavity causes empyema, and usually leads 

' AiiJ<t. Merl. Gfiz., Augu.st 20, 1895. He gives the proportion for all Australia as 
] to 206, at all apes. 

' *' Hvflatid Disease, with Special Reference to its Prevalence in Austnilia," by 
John Dayies Thomas, M.D. (Ecliteil by Dr. Lemlon), 1894, vol. i., p. 120. 

'"Clinical Lectures on Diseases of the Liver," Sec. E<1., 1885. 



408 ' HYDATID DISEASE. 

to a fatal result unless operated on. Suppuration of the sac may 
occur s])ontaneously ; but it is found to occur with great frequency 
as an after result, immediate or later in life when resort has been 
made to tapping. The constitutional disturbance produced by sup- 
puration is grave, and is characterized by pyrexia, rigors, rapid 
pulse, and emaciation. In the treatment of hepatic hydatid the im- 
mediate dangers of puncture and aspiration, even with the strictest 
aseptic precautions, are great. 

At a later date suppuration in the sac very frequently occurs and 
requires the radical operation. Thus the large experience gained in 
Australia ^ thoroughly supports the reasons and statistics advanced 
by Thomas for the conclusion that the safest method of treatment 
is by abdominal section, immediate removal of the mother cyst, and 
stitching the sac to the parietal wound (Lindemann's operation). 
Further, experience shows that in simple cysts that have not sup- 
purated the intraperitoneal method gives the best results." 

Hydatid of the lung is, in Australia, by no means rare in chil- 
dren. The symptoms do not differ from those observed in the adult, 
the most prominent being a dry cough with little or no expectora- 
tion, but with occasionally slight haemoptysis ^ and dyspnoea on ex- 
ertion. Complaint of pain in the chest is not made unless the cyst 
be large. Slight haemoptysis before rupture proceeds from the con- 
gested lung surrounding the sac. It may be profuse after rupture 
or incision. Pyrexia and emaciation are not marked unless the cyst 
has suppurated. 

The physical signs produced by a hydatid of medium size near the 
surface, at or towards the base, to some extent resemble those of a 
localized pleural effusion. Together with deficient expansion there 
is an area, tolerably sharply defined, of absolute dullness, with a 
sense of increased resistance on percussion. With these signs there 
is absence of respiratory murmur, vocal fremitus, and resonance in 
the same region. Above, there is increase of respiratory murmur 
and of resonance on percussion. If the cyst be large, there is bulg- 
ing of the chest wall, with distension of the intercostal spaces, where 
fluctuation can frequently be obtained. The heart, liver, or spleen 
may be displaced. 

The diagnosis, often difficult (unless there be no general grounds or 
reason to suspect hydatid, which is not the case in Great Britain or 
America), must depend partly on the complete absence of vocal 
resonance, but mainly on the general condition of the patient, who 
will be free from emaciation or fever, and upon the prolonged history,; j 

' Trans. Anst Med. Congress, 1892 ; Aiist. Med. Gaz., 1895. * 

'^'QonA, Brit. Med. Journ., 1891, vol. i., p. 795. Conf. Intercolonicd Quarterly 

Journal, February, 1895. 

3 Graham states ( " Hydatid Disease," 1891) that in some cases haemoptysis may 

not occur. 



J 



HYDATID DISEASE OF THE HEART. 409 

If the cyst be deeply situated, there may he niiieh difficulty in reeoiiiiiz- 
iog its existence. The compression of the lung tissue produces a 
high-pitched or tympanitic note on percussion. The physical signs 
of hydatid cyst at the apex resemble those of early phthisical con- 
solidation. The diagnosis must depend on the absence of breath- 
sounds. If the cyst ruptures into a bronchus, an acute suffocative 
attack occurs, and the lungs are Hooded witli Huid, wliich is cnuglunl 
up in large quantities. Later, shreds of the cyst wall or daughter 
cysts are brought up after severe cough with suffocative attacks. 
The physical signs change, the patient suffers from fever and night 
sweat-s, and the profuse purulent expectoration contains slougliing 
particles. In time clubbing of the lingers is ju'oduced. Owing to the 
fluid contents of the cyst being replaced by air, the physiciil signs be- 
come those of pulmonary cavity, or, if a communication is established 
with the pleura, of pneumothorax. The diagnosis must rest mainly 
on the history, on the recognition of any fragments of the cyst wall 
which may be coughed up, on the general condition of the patient, 
and on the fact that in children large cavities are very rare. The 
absence of the bacillus tuberculosis from the sputa will afford con- 
firmatory evidence. 

Tiie treatment of pulmonary hydatids must be surgical. Thomas 
expresses the opinion that the probability that any case in which 
pulmonary hydatid can be diagnosed will undergo spontaneous cure 
is virtually nil. The best treatment appears to be free opening into 
the sac, and the immediate removal of the parasite. Puncture of 
hydatids of the lung, from the dangers immediate and remote, must 
be looked upon as a most hazardous proceeding.^ Removal of the 
cyst is followed by re-expansion of the lung.^ 

Hydatid disease of the heart is a very rare event at any age, 
but an unusually large proportion of recorded cases have occurred in 
early life. Out of 33 cases collected by Thomas, in which the age 
is given, 4 occurred under ten years of age and 11 between elev^en 
and twenty. In the majority of cases the parasite was imbedded in 
the muscular substance. The condition is not necessarily fatal, since 
the parasite may die, but the more usual termination is sudden death, 
which may be brought about by rupture into one of the cavities of 
the heart, generally into the right side. 

A considerable number of cases of intracranial hydatids have been 
recorded in children. In 79 cases colhc^ted by Thomas ' 19 per 
cent, occurred under ten years of age and 34 per cent. l)etween 
eleven and twenty, so that more than half the cases occurred under 
twenty. The cerebral hemispheres are the most usual site. In the 

• Tram. Med. Conffress Aust., 1892, pp. 381 and 441. 
«Lendon, Auxt. Med. Gaz.y 189o, p. 477. 
^ Loc. cit.j vol. ii., p. 86. 



410 HYDATID DISEASE. 

majority of cases there is a single cyst, which is generally of 
spherical or ovoid form. If a capsule be present it is usually fine 
and soft. 

The symptoms of intracranial hydatids are those common to intra- 
cranial tumor. The general symptoms — headache, vomiting, and 
optic neuritis — may all be present, but in some cases they are not 
well marked, and the only symptom of which the patient complains 
is headache, occurring in paroxysms and aggravated by movement. 
Such cases may terminate suddenly, without any suspicion of the 
real cause of the headache being entertained. As will be gathered 
from what has been said, localizing symptoms may be absent. Epi- 
leptiform seizures, in some instances limited to one side of the body, 
have occurred, and in others definite hemiplegia, although this has 
been absent in cases in which from the size of the hydatid found 
after death it might have been expected to occur. In some cases 
the cranium has been enlarged, generally or locally, and in a few the 
bones have become perforated. Vertigo is not a constant symptom, 
and a staggering gait has been noticed chiefly in cases of cysts oc- 
cupying either the posterior lobes of the cerebrum or the cerebellum. 
Blindness would appear to have been produced in an unusual pro- 
portion of the cases. 

The duration of the disease is now well ascertained ; but Thomas 
states that the average duration of life (at all ages) after the appear- 
ance of the first cerebral symptoms is about one year. The diag- 
nosis, even in those cases in which well-marked symptoms of intra- 
cranial tumor arise, must generally be in the main conjectural. If 
the symptoms point to cerebellar tumor, it is extremely unlikely to 
be hydatid ; but in chronic cerebral tumor the possibility of its be- 
ing a hydatid cyst should be borne in mind, and the probability 
would be increased if there is evidence of localized thinning of the 
cranial bones. 

The treatment of intracranial hydatid by drugs offers no prospect 
of improvement, and relief can only be afforded by surgical means. 

Hydatid disease of the kidney or spleen is extremely rare. 
Thomas could find no recorded cases under ten years of age, though 
he mentions a few between the ages of eleven and twenty. Cases of 
hydatid disease of the spinal cord and superficial structures are 
among the curiosities of medical literature. 



CHAPTER XXXVI. 
DISEASES OF THE GEXITO-UKIXAKY SYSTExM. 

The Urine — Alhuniimiria — Albuinimiria of Puberty — IT.Tinaturia — ILvnioglo- 
binuria — Pyuria — I>isea.-<es of the Kidney : Diffuse Nepliritis ; Glonierulo-Ne- 
pliritis ; AniyUnd IVsreneration ; Urie Acid Diathesis ; Renal Calculus ; Hy- 
dronephrosis ; Pyelitis ; Perinephritic Abscess ; Congenital Cystic Disease of 
the Kidneys ; Tumoui-^ of the Kidney. 

Urine. — The kidneys are relatively lartrer at birth than in the 
adult : the weight is to the total body weight as 1 to 120 instead of 
1 to 240 as in the adult. The lobulation is marked ; the lower end 
of the kidney reaches almost to the level of the iliac crest. The 
organs are active during fcetal life, and it is not uncommon for some 
urine to be passed immediately after birth. On the other hand, no 
urine may be passed for twenty-four hours, and there are great vari- 
ations in the quantity. The urine first passed has a specific gravity 
of about 1010, and is often turbid from the presence of urates, epi- 
thelial cells and mucus. Uratic infarctions are very frequently pres- 
ent in the terminal straight tubules of the kidneys at birth, and are 
probal)ly physiological. They consist of uric acid, ammonium urate, 
and amor})hous urates, mixed with mucus and epithelial cells. They 
are washed away usually within a week or a fortnight, l:)ut may ])er- 
sist for seven or eight weeks ; these uratic drhrix produce brickdust 
red stains on the napkins. In early infancy the urine is quite 
colorless or of a very pale primrose color (Chablis wine), and odor- 
less, or nearly so. The specific gravity falls soon after birth, but 
rises again at the beginning of the third week to 1006 or more. It 
Ls difficult to collect the whole of the urine in infancy, as defa?cation 
is usually accompanied by micturition ; but the quantity passed daily 
shows consideral)le variations in different children and at different 
ages. It appears to increase rapidly at first, and l)y the tiiird week 
is relatively more copious than in the adult ; this excess persists 
during the suckling j^eriod. Specimens may be obtained by keeping 
a perfectly clean dry sponge in contact with the genitals, or by pass- 
ing a catheter. After the third or fiuirth month a skilful nurse will 
usually Ix' able to obtain the greater j)art of one or two micturitions 
during the day in a clean vessel. The quantity ])assed at each mic- 
turition does not vary much. This uniformity may be attributed in 
part to the uniformity of the diet, and in part to the fact that in 

411 



412 DISEASES OF THE GENITO-URINARY SYSTEM. 

young infants micturition is a purely reflex act. The age at which 
some voluntary control is acquired varies much ; some power of hold- 
ing water may begin to be exercised soon after the sixth month, but 
even earlier than this the infant may acquire the power of micturating 
when solicited. A healthy infant of two to three months old may 
be expected to micturate about ten times in the twenty-four hours, 
and to pass altogether from 8 to 10 fluidounces ; by six months the 
daily quantity will be doubled or trebled, so that before weaning as 
much as a pint and a half may be passed. After weaning, this 
quantity will decrease, and a child of two or three years may not 
pass more than a pint, or a pint and a quarter. The reaction of the 
urine in early infancy is neutral, or slightly acid, seldom alkaline. 
The quantity of urea in early infancy is relatively large ; it increases 
as the infant grows, but not in proportion to its increase of weight. A 
notable decrease in the amount commonly occurs at weaning, and an 
attack of diarrhoea may cause a great diminution. The statements as 
to the proportion of uric acid present are conflicting, and it is prob- 
able that its amount depends a good deal upon the condition of 
nutrition and of the digestion. A trace of albumen may be discover- 
able during the first few weeks of life ; probably it is to be attributed 
to the irritation produced by uratic infarcts, and is not of serious 
significance. 

[The factor of excretion is such an important one and the well-being 
of the subject depends to such an extent upon its proper performance, 
that examination of the urine is of great importance. Much may be 
learned from such examination. We do not of course find actual, 
organic disease in all cases but we may determine to what extent 
metabolism is going on and in what respect it is deficient, and may 
thus gain valuable information in the matter of treatment. 

Investigation of the urine of children has not been carried out as 
extensively as the importance of the subject demands. Normal 
physiological standards are necessary with which to compare the re- 
sults obtained from the examination of pathological specimens, but 
comparatively few investigations have been made into the urine of 
healthy children, and well-established definite standards of urinary 
analysis in children at different ages have yet to be accurately deter- 
mined. Many analyses from children of every year up to puberty 
must be made before these standards can be established ; for the com- 
position of the urine varies from year to year in childhood. The 
publication of analyses of pathological cases is also important, and 
from a study of such, much will undoubtedly be learned which will 
be of help in preventing the development of actual organic disease 
later in life. We must bear constantly in mind in the treatment of 
children that we are dealing with an organism that is plastic and still 
^ Longet quoted by Ballantyne, " Diseases of Infancy," 1891, p. 178. 



URISE. 



•413 



in the formative periixl, witli only tendencies, not actual habits es- 
tablished. There can be no doubt of the truth of AVeissniann's theory 
that it is tendencies, not actual traits, which are transmitted from 
parent to offspring. The earlier we attempt to mould these tendencies, 
the more impression can we make upon them. The study of a large 
number of urinary analyses from children with known hereditary 
tendencies will undoubtedly show along what lines these children are 
apt to develop, and, if these lines be in the wrong direction, the first 
step towards correcting them has been taken. It is the reviser's be- 
lief that from careful, exhaustive study of the urine much may be 
learned of value in heading off serious organic disease of the kidney 
later in life. 

The tables given below are compiled from a study of the urine of 
70 healthv children ranging; in aii:e from 1 dav to 12 vears, 48 girls 

« coo » .Jo 



yrs. 




Sex. 


•J: 


c -; Specific 
= ^ Gravity. 

1 


Urea, 
per 
cent. 


Total 
Urea, 
grm. 


Chlo- 

rides, 

per 

cent. 


Phos- £■£ -.Bf 
phates, « f —> d 

^'- n W 


Urea to 1 kIg. 

Body Weight, 

grm. 


.. 


16.8 


2M 


5 


358 1024.0 


o o 


7.87 


12.5 


12.00 l.OS 21.3 


.468 


1 


16.9 


f7M 
\4F 


31 


299 1027.1 


2.9 


8.67 


11.17 


^2 


1.41 17.6 


.513 




16.S 


( IM 
7F 


17 


392 1024.5 


2.C 


10.19 


10.37 


8.89 


1.13 23.3 


.606 




^ ,7 


IF 


2 


405 1023.0 


2 7 


10.94 


11.00 


6.50 


1.13 24.2 


.655 


7 


20.9 


flM 
\3F 


4 


5G4 lOlS.O 


1.1 


6.20 


7.00 


5.63 


0.85 26.9 


.296 




22.6 


f2M 
\7F 


20 


628 1021.1 


2.2 


13.82 


9.16 


7.32 


1.11 27.8 


.611 




26.2 


(1 M 

\yF 


25 


731 1020.7 


2.3 


16.81 


8.46 


7.61 


1.10 27.9 


.641 


l'» 


27.5 


(2M 
\6F 


15 


768 1023.5 


2.1 


11.28 


9.29 


6.85 


1.10 27.0 


.502 


11 


27.2 


JIM 
(3F 


7 


716. 1018.8 


2.3 


16.83 


10.03 


7.50 


0.92 26.3 


.618 


12 


36.4 


f2M 
i3F 


8 


829 1021.5 


2.8 


23.21 


9.27 


6.77 


1.00 


22.7 


.637 


Tot, 




< 10 M 


134 


i 













and 22 boys. The results are classified as to age and averaged ; 146 
8|x*cimens were examined, it being better to examine two or more 
from a limited number of ca.ses than a single sj^ecimen from a larger 
number of children. The results justified this metluKl of ])roc<'dure, 
a.s considerable variations in the amount of urine pa.s.sed at diifercDt 
times were noticed. 



414 


DISEASES OF THE GENITO- 


URINARY SYSTEM. 


Age. 


Weight. 


Sex. 


.s «■ 


o 

< 


M 


^1 




1- 


1^- 
1- 


Kemarks. 


1 day 
12 days 

3 wks. 

3^ wks. 

4 wks. 


3.18kiL 
3.86 K. 
4.14 K. 

4.25 1^ 

4.47 0. 

9.98 a 


F 


3 

36 




1003 
1001 

1005 

1004 
1021 
1026 
1030 

1026 

1028 

1026 
1020 


.4 

.1 

.5 

.2 

.1 
2.6 
2.7 
2.5 

2.3 

2.8 

2.1 

1.7 


Passed at 1 2 M. 
" 9 A.M. 

'' 4 P.M. 


1 hour after 
breast. 

Dentition slow. 
1 Specimen. 

Mixture night 
and day 
urine. 








30 

23 
9 




M 








1 year 
1^ years 

13 mos. 

20 mos. 

20^ mos. 

2 years 






12 
18 

11 

16 

8 
6.5 


16 
11 

11 

13 

12 
6 


1.75 
1.25 

1.00 

1.75 

1.00 
1 


9.76 kil. 

(21ilbs.) 


F 
F 

M 




195 




290+ 

3254- 
450 


} 


14.07 K. 

(31 lbs.) 


M 

1 






r3M) 

IsfI 


12 specimens in al 


1 









Observations were made upon the following points : Total amount 
of urine in twenty-four hours, color, reaction, specific gravity, pres- 
ence or absence of albumen and sugar, percentage and total urea, 
percentages of the chlorides, phosphates, and sulphates. The sedi- 
ment was examined macroscopically and microscopically. Theferro- 
cyanide and nitric acid tests were employed for the albumen, the urea 
was estimated by the hypobromite method, Doremus' ureometer being 
used, the percentage of the chlorides, phosphates, and sulphates de- 
termined by centrifugal analysis as recommended by Purdy, the 
tubes being revolved three minutes at a speed of 1,100 revolutions 
per minute. 

Examination of these results in detail show several interesting 
points : 

Amount. — The daily amount is much less than that recorded by 
most authors, except Herz, whose analyses upon 60 cases, 30 girls 
and 30 boys, correspond approximately with the reviser's. Other 
observers, however, Schabanowa, Cruse, Camerer, Berti, Pollak and 
Martin-Huge record larger amounts. The difficulties of collecting 
urine from active, healthy children are of course great, and the sus- 
picion at once arises that all the urine in these cases was not saved ; 
great care was taken in this respect, however, and no cases about 
which there was any doubt were included in these analyses. Fur- 
thermore the specific gravity confirms the amount. 

Specific Gravity. — This, as we see, is comparatively high, a con- 



URINE. 415 

dition we should expect in children passing but a small amount. 
Had the amount actually been larger, we should have expected a 
lower specitic gravity. 

The specitic gravity of one young infant recorded is low, coincid- 
ing with the well-known observations at this period ; it mnged from 
1,001 to 1,005 from the 13th day to four weeks. It is, however, 
generally higher during the tirst two days of life before the establish- 
ment of the breast-milk. It drops after tliis and continues low 
throughout the first year, owing to the fluid character of the in- 
fimt's food. During the second year, solid food being added to the 
diet, the specitic gravity rises and in four cases, aged respectively 
twelve, thirteen, eighteen, and twenty months, was found ranging 
from 1,026 to 1,030, the urine being a mixture of the day and night 
elimination.^ 

Urea. — The estimation of this constituent is perhaps the most 
important of all the urinary solids, being as it is an index of 
general metabolic activity. As we should expect from their greater 
activity, and as Purdy and Foster state, we find the urea excretion 
in children relatively higher than that in adults. The low percen- 
tage noted during early infancy is, of course, due to the quiescent 
state of the child. Martin-Ruge, however, reports wide variations 
in single specimens during the first ten days of life, ranging from 
6 per cent, to 1.9 per cent. Schift' also gives wide variations, plac- 
ing averages at from .28 per cent, to 1.7 per cent, during tlie first 
fourteen days. AVhy there should be such a wide range in the ex- 
cretion of this substance at a time of such quiescence it is difficult 
to see. Possibly greater metabolic activity after nursing may ac- 
count for it. I have no statistics upon the relative amount of urea 
in urine passed just before, just after, and some time after feeding. 
The few observations made at this age show without exception very 
low percentages, from .4 per cent, to 1.2 per cent., lower than those 
cited. After the first year it rises, and from three to twelve years, 
the 133 specimens show a higher general average than that usually 
given. Verordt's percentage based on seven cases is recorded at 1.1 
per cent, to 2 per cent., four being below 2 per cent., one 2 per 
cent, and one 2.6 per cent, and one not given. This represents the 
adult average, whereas so great is the j^hysical activity of the grow- 
ing child, so active is his metalx)lism, that a large amount of urea is 
formed, and while it may l>e argued that most of his nitrogenous 
foTKl goes to the building up of the rapidly growing body, and thus 
the amount of urea formed in the urine would naturally be less, it 
would seem more rational to ex|)ect a greater elimination of this 
substance. Not only are my average percentages higher than the 
average given for adults, but individual cases show a remarkably 
high jxTcentage of elimination of urea, eight children having over 



416 



DISEASES OF THE GENITO-URINABY SYSTEM. 



3 per cent., the highest being 3.7 per cent. The amount of urea per 
kilogram of body weight, while slightly higher than the ratio given 
for adults, is lower than that given by other observers, as we should 
expect from the smaller amount of urine. 

Chlorides. — The chlorides were found quite constant at about 11 
per cent, up to seven years, after which they were about 9 per 
cent. 

Phosphates. — The phosphates were found to be from 8 to 11 per 
cent, from 3 to 5 years ; 5 to 7 per cent, from 6 to 12 years, the 
adult range being about 8 per cent. It has been suggested that the 
smaller amount of phosphates found in the urine of children is due 
to the fact of the phosphoric acid being retained in the body for the 
growth of bone. One specimen from a year old boy showed 16 per 
cent, and as he was somewhat slow about teething, though otherwise 
perfectly healthy, the question suggested itself as to whether sub- 
stances which normally go to build up the teeth, were being elimi- 
nated as phosphates, and if so, why ; digestion was absolutely nor- 
mal. No conclusions, hoAvever, can be drawn from one solitary 
instance ; the observation is merely of speculative interest. 

Sulphates. — The percentage of sulphates was 1 to 1.2 per cent., 
slightly higher than in adults, .8 per cent, being their average. 
Purdy states that the sulphates run parallel with the urea. 

Albumen and Sugar. — Neither albumen nor sugar were detected in 
any specimen. So much had been said about a physiological albumi- 
nuria that I had expected to find albumen in one or more specimens. 
It must be remembered, however, that my cases were examined but 
two or three times, and some only once, and that therefore a tran- 
sient temporary albuminuria might have come and gone between ex- 
aminations. 

Sediment. — Examinations of the sediment showed nothing of 
special interest in any case. 

Reaction. — The reaction was acid in all cases, though of course 
varying in intensity in different specimens. 

Color. — The color in most cases was pale, in the rest normal. 

Looked at as a whole the records show three factors of chief im- 
portance : the small amount of urine, the high percentage of urea, 
and, a natural result of these two, a high specific gravity. In other 
words, these children were passing a comparatively concentrated 
urine. They were all healthy, robust children, eating, sleeping, and 
digesting well, and of average weight. They were average Ameri- 
can-born children, living in an asylum under American customs and 
regime, though mostly of foreign parentage. The chief point of dif- 
ference between these analyses and those made by foreign observers 
is the larger amount of urine recorded by the latter. 

It is interesting to note in this connection the amount of urine in 



i 



ALBUMINURIA OF PUBERTY. 417 

adults, as given by observers in dittoront countries. Simon gives 
the following : 

Salkowskv (Gcrmanv) loOO to 1700 o.c. 

Jaks^'h (Austria)....." loOO to 2000 c.i^. 

Landois c't Sterling (England) 1000 to loOO c.e. 

Gaiitier (France).". rj">0 to LSOO e.c. 

Simon (America) 1000 to 1300 c.c. 

(Females) 900 to 1000 c.c 

It would seem from these tables that American adults, and also 
children, pass smaller amounts of urine than the people of other 
<^>untries. 

1 his factor of a concentrated urine, small in amount, occurring in 
ciiildren, can but l>e regarded as unfortimate, inasmuch as such urine 
is a source of constant irritation to the kidney and hence likely to 
pave the way for organic disease of that organ. Especially in 
those children with a lithaemic or rheumatic inheritance would such 
a condition if long continued be a serious matter. They, and indeed 
all children, should be encouraged to drink freely of milk and of 
water. This is all the more important when we consider the 
numerous conditions which directly and immediately, indirectly and 
remotely, act as causes of nephritis, a disease more common in early 
life than is generally supposed.] 

By albuminuria is to be understood the presence in the urine of 
albumen, recognizable by the ordinary clinical tests : (1) Fuming 
nitric acid in the cold, and (2) boiling, with subsequent addition of 
an acid, preferably acetic acid. 

Albuminuria is evidence of changes in the renal structures. The 
changes may l)e transient, and limited to the epithelium of the 
glonuTuli and tulniles. 

Albuminuria of Puberty. — It is not uncommon in children of either 
sex, but most often in boys, to meet with cases in which, at about the 
time when the changes attending puberty are commencing, albumen 
api>ears in the urine in small quantities. Such patients are described 
as "delicate" ; they are thin, have a poor appetite, are easily tired, 
and suffer often from headache, but they do not present anasarca. 
The albumen may l)e present only during j)art of the day (rj/rlic 
a/bumlnnria)y and will then usually disaj)pear if the patient be kept 
in l)e<l. The amount is increased by exertion. In some cases 
granular or hyaline casts may be present ; whether this be so or not, 
it is safer to look u|)on such ca.ses as being, in reality, examples of a 
very mild form of subacute or chronic nephritis, and the ])atient 
should be treated on the same principles as those followed in the 
management of convalescence from subacute nephritis. The prognosis 
is good if proper treatment can be instituted. 



418 DISEASES OF THE GENITO-URINARY SYSTEM. 

Haematuria. — Blood derived from the kidneys is mixed uniformly 
with the urine, to which it gives a smoky appearance, or, if in larger 
quantities, a bright red or deep porter color. A minute quantity 
does not alter the color of the blood and can be recognized only by 
microscopical examination. Clots may be derived from the pelvis of 
the kidney or from the bladder. Blood from the bladder may be 
mixed intimately with the urine or passed at the end of micturition ; 
its commonest cause is stone. 

Hsematuria may be due to the effect on the kidneys of malignant 
attacks of the acute specific diseases, or of certain poisons (e. g., can- 
tharides, turpentine, carbolic acid ) to acute glomerulo-nephritis (e. 
g., post-scarlatinal nephritis), to congestion, as in heart disease, 
whether congenital or acquired, to renal infarction, to tubercle, to 
new growths, or in certain tropical and sub-tropical climates to the 
filaria sanguinis hominis, the bilharzia, or to malaria. Injury of the 
kidney, or of any part of the urinary passages, may lead to the ap- 
pearance of blood in the urine. Calculus in the pelvis of the kidney 
is, in childhood, one of the commonest causes of hsematuria not due 
to acute febrile disorders. The quantity of blood varies ; it may be 
absent altogether for considerable periods, it may be present in 
microscopical quantity only or, again, in sufiicient amount to alter 
the color of the urine (smoky or red). Transient recurrent hsema- 
turia may also be observed in cases in which the urine contains 
microscopical crystals of oxalates or uric acid. Occasionally blood, 
apparently derived from the kidneys, is present in the urine of chil- 
dren without any discoverable cause (renal epistaxis, Gull). 

Haeinog'lobiniiria is a condition in w^hich the urine contains free 
haemoglobin or methsemoglobin. According to the quantity of 
either present, the urine has a smoky, lake, brown-red, or black 
color. It deposits a dark brown sediment, containing granular pig- 
ment, cellular debris, a few cells, and dark-colored urates. 

It may be produced (1) by certain poisons, such as arseniuretted 
hydrogen, carbon monoxide, potassium chlorate, carbolic acid, and 
naphthol in large doses ; (2) by acute infectious diseases, as, for 
instance, scarlet fever, typhoid fever, and malaria ; and it is said 
also by (3) exposure to cold and severe exertion. (4) Hsemoglobi- 
nuria of the new-born is referred to elsewhere. (5) Paroxysmal 
haemoglobin uria, a condition characterized by the occasional passage 
of urine containing free blood pigment, has been observed occasion- 
ally in children, generally in association with Raynaud's disease. 

Pyuria. — Pus in the urine may be derived from the pelvis of the 
kidney, from the bladder, from an ulcer opening into the urinary 
passages, from the urethra in boys, and from the vagina and vulva 
in girls. Pus from the kidney is intimately mixed with the urine, 
which, except in pyelitis secondary to cystitis, is acid. Pus from 



DISEASES OF THE KIDNEY. 419 

the bladder is usually aeeompanied bv nuioh ropy nuu'us, which is 
most copious towards the end of uiieturition. The urine is alkalin(\' 
and passed at frequent intervals, the act being attended by nuieh 
pain. Pus from the urethra passes before the urine ; it can usually 
be squeezed from the meatus by mani]ndation, and micturition is 
accom}n\nied by scalding pain. Pns from the vagina is mixed with 
flakes of lymph, and contains much vaginal epithelium, wliile the 
urine drawn off by a catheter, or passed immediately after thorough 
ablution, contains none. 

Diseases of the Kidney. 

During the pyrexial period of many acute diseases, diphtheria, 
typhoid fever, pneumonia, scarlet fever, small-pox, erysipelas, influ- 
enza, septic diseases, and acute enteritis, albumen appears in the 
urine in a large proportion of cases. It may be present on one or 
two days only and in very small quantity ; but in other cases, es- 
pecially in diphtheria and pneumonia, the amount may be large. As a 
rule, it disappeai-s early ; often, in fact, as soon as improvement in 
the general symptoms commences, and before convalescence is estab- 
lished. The urine may contain a little blood, but seldom in qnantity 
sufficient to render it smoky. The course of the i)rimary disease is 
Dot, as a rule, much influenced by the renal complication, though 
extensive granular degeneration of the epithelium will increase the 
risk of death from toxtemia. 

The lesion of the kidney is a diffuse nephritis, which involves the 
elements of the cortex to different degrees in different cases. In 
the most typical form, that which is met with most often during the 
acute stage of pneumonia, scarlet fever, diphtheria, typhoid fever 
and small-pox, the kidneys are enlarged and full of blood, and there 
is marked concfcMwn of the cortical substance. The capillaries of 
that part are dilated, and the glomeruli distended with blood, which 
may become effused also into their capsules and into the adjacent 
part of the uriniferous tubules. The cells of the convoluted tubules 
are in a condition of cloudy swelling, and the lumen contains leuco- 
cytes in a mucous matrix. In other cases, especially in erysipelas, 
septic fevers, and the early stage of scarlatinal ne])hritis, more rarely 
in diphtheria and typhoid fever, the inflanmiation is nuiinly infcr- 
Uihular. I>eucocytes are found in large numbers between the tubules 
and amund the glomeruli, the changes in the latter and in the 
cells being slight. The kidney is large, and pale or mottled. In 
the most severe cases the element which suffers most is the venal 
epithelium. The kidneys are large, smooth, and have a uniform yel- 

' There is a peculiar form of cystitis, due apparently to the hariUns colt rommvni*, 
in which the urine remains acifl. Jt is usually a mild diH<^)r(ler, hut is sai<l to he at- 
tended sfjmetimes hy syn)ptoms of typhoid type. 



420 DISEASES OF THE GENITO-URINARY SYSTEM. 

lowish or greyish surface on section. The cells are swollen, and 
granular from fatty degeneration. This ^'coagulation necrosis'' is 
met with especially in the severest cases of diphtheria. It is due to 
the irritative action of toxic bodies, produced during the fever, or 
perhaps, in some cases, to the presence of bacteria. [The presence 
in the kidney of the Klebs-Loefflsr bacillus, of the streptococcus, 
and of the staphylococcus pyogenes aureus, each alone and also as- 
sociated with each other, repeatedly demonstrated at autopsy, makes 
it probable that the changes in this organ are due to a micro-organ- 
ism. The streptococcus and staphylococcus pyogenes aureus have 
been found in the kidney in scarlet fever as well as diphtheria, oc- 
curring sometimes alone, sometimes together. Lemoine has found 
the streptococcus in the urine also of scarlatinal patients, 22 cases 
showing albuminuria, 1 showing no albumen.] 

The diffuse congestive nephritis, described above as occurring dur- 
ing the pyrexial period and ceasing before convalescence or during 
its early stage, is sometimes succeeded by an acute or subacute glom- 
erulo-nephritis. This occurs with particular frequency and severity 
after scarlet fever (post-scarlatinal nephritis), but may be observed 
also after typhoid fever, diphtheria, mumps, tonsillitis, measles, 
variola, varicella, pneumonia, acute rheumatism, osteo-myelitis, and 
other inflammatory affections, including, it is said, extensive simple 
impetigo. It may occur, also, as a complication of malaria. In 
some cases it follows, without any recognized antecedent illness, on 
exposure to cold, which has been assigned as the determining cause 
of post-scarlatinal nephritis. The kidneys are large and soft. In 
the early stage they are congested and full of blood, presenting often 
haemorrhages at the surface and between the tubules. At a later 
stage they are pale, with a yellow or grey tinge, and present scat- 
tered white streaks between the tubules and prominent glistening 
granules, which are enlarged glomeruli. The enlargement of the 
glomeruli is due to a thickening of the capsule and proliferation of 
the cells, so that the cavity is distended by a mass of flattened cells 
which compress the capillary loops. The epithelial cells of the con- 
voluted tubules are granular and detached in places, and the lumen 
of the tubules is filled with their debris, with leucocytes and with 
exudation. The epithelium of the straight tubules is less altered, 
but their lumen contains often opaque or hyaline cylinders. The 
arterioles, in relation with the glomeruli, are often involved in the 
inflammation, and may be obstructed. The lesions, therefore, are 
such as favor the occurrence of anasarca and uraemia — the transuda- 
tion of water being hindered by the compression and contraction of 
the glomerular loops, while the excretion of toxic matters is dimin- 
ished owing to the degeneration of the excreting epithelium. 

Scarlatinal nephritis, which is the type of glomerulo-nephritis, 



SCARLATINAL SEPHEITIS. 421 

first, as a rule, produces symptoms which attract atteution during 
the second week of the ilhiess — that is to say, durino; the stage of 
desquamation. Not infrequently its appearance is delayed until 
the third, fourth, or even fifth week. In some cases the onset ap- 
pears to be determined by exposure to cold. The symptom which 
is noticed earliest and is most characteristic is anlema, first usually of 
the eyelids in the morning, then of the conjunctivir and face, then 
of the lower limbs, of the front of the abdomen and chest, and over 
the sacral region. Subcutaneous c^ema may occur, indeed, in any 
part, and the variability in its degree and position is remarkable. 
It is soft, and long retains the impression of the finger. The skin 
is pale and dry. Fluid may be effused into the pleura, pericar- 
dium, and peritoneum. The meninges and brain are anlematous. 
(Edema of the glottis may occur suddenly and produce death. Albu- 
men is, as a rule, present in the urine before anasarca develops, and 
continues after it has disappeared ; but the anasarca may appear first, 
and it may even hapi)en that at no time in the course of the case is 
albumen found in the urine. The quantity of urine diminishes pro- 
gressively, and at the height of the attack only a few ounces, which 
may l>ecome almost solid on boiling, may be passed in the twenty- 
four hours. The urine usually contains blood, often in sufficient 
quantity to render it smoky. On microscopical examination, in ad- 
dition to blood cells, hyaline and granular casts and epithelial debris 
will be found. 

The oiu^et of glomerulo-nephritis may be (piite insidious, and 
anasarca makes its appearance without any premonitory symptoms. 
It may be preceded for a few days by headache, nausea, vomiting, 
and pain in the loins, and sometimes by slight ])vrexia. Eclampsia 
may Ix' an early, in fact, the earliest symptom, but more often the 
ef)nvulsions occur after anasacra has become marked. They are 
usually preceded and accompanied by great diminution in the quan- 
tity of urine, or by its entire suppression. The first attack is fol- 
lowed usually, at intervals of a few hours, by others. If, after the 
first, the child remains free for twenty-four hours, there is good 
ground for ho|>e that no second attack may occur ; but convulsions 
repeated at short intervals are of very bad omen, for, as a rule, fatal 
cnma ensues. In some cases a)ma sets in without antecedent eclamj)- 
Death may Ix' brought about also by serous effusion into the 
, ine, rjr by intercurrent pneumonia, ])ericarditis, or pleurisy. 
Dilatation of the heart is frequent, and death may occur from car- 
diac failure. Sudden loss or impairment of vision due to cedema of 
the discs or, more rarely, to neuro-retinitis, is an occasional com|)li('a- 
tion of glomerulo-nephritis. Recovery of sight is as sudden, and is 
usually complete. 

The course of glomerulo-nephritis varies very greatly. In some 



422 DISEASES OF THE GENITO-URINARY SYSTEM. 



< 



cases it is a very mild disorder, lasting from four to six weeks, pro- 
ducing few symptoms beyond malaise, oedema, anaemia, and moderate 
albuminuria. In others it is a very acute and severe disease, bring- 
ing life into great danger in a few hours. In others, again, it runs 
a very chronic course, oedema coming and going, and albuminuria 
persisting in varying degree for many months. As a rule, if the 
patient escape uraemia, recovery takes place sooner or later ; but, in 
the more chronic cases especially, the patient remains for long liable 
to fresh attacks on exposure to cold, or during any infectious disease 
from which he may suffer subsequently. In these more chronic 
cases the quantity of urine and the proportion of albumen which it 
contains, and the amount of urea eliminated, may vary very much 
from time to time, and even from day to day. During remissions 
the quantity of urine and of urea increases and the oedema diminishes, 
but the amount of albumen does not bear any relation to the other 
constituents of the urine. As a general rule, the larger the amount 
of albumen in the urine the greater the danger of the occurrence of 
uraemic complications. While the albuminuria continues the liability 
to a sudden exacerbation remains, and the longer the period during 
which albuminuria has persisted the less the expectation of ultimate 
escape from these dangers. In some cases granular contracted kid- 
ney is produced, more or less hypertrophy of the heart occurs, and 
the urine is copious and of low specific gravity. Albumen may be 
absent from the urine for long periods, or be present only in traces ; 
but exacerbations, in which the urine decreases while the proportion 
of albumen it contains increases, are frequent. 

[Chronic Nephritis. — It is now generally believed that while 
chronic interstitial nephritis is in childhood necessarily rare, chronic 
parenchymatous nephritis occurs more frequently than has been 
hitherto thought. It most commonly has its starting point in scar- 
let fever, though any of the infectious diseases may cause an acute 
nephritis which may run on more or less insidiously into the chronic 
form. A certain number of these cases are without apparent origi- 
nal cause, but careful and minute inquiry into the previous history 
will show in most instances the occurrence of some infectious dis- 
ease, scarlet fever, diphtheria, measles, pertussis, influenza or ton- 
sillitis, any one of which might have acted as an exciting cause of 
renal trouble. Chronic intestinal trouble also undoubtedly acts as a 
source of renal irritation, if not of actual nephritis. 

The history is generally that since some acute illness, perhaps sev- 
eral years before, the general health has been impaired. It is un- 
usual to hear complaints of any one specific symptom, but rather an 
account of general and indefinite malaise, capricious appetite, rest- 
less sleep, lack of energy, perhaps some slight oedema, pallor, head- 
ache, and often constipation. Physical examination may be abso- 



CHBOyiC XEPHRITIS. 423 

liitely Degative, except that usually ^vc tiiul a low porcentagc of 
hivmoglobiu. It may he thouglit that the e;\se is ]niroly intestiual, 
and uudoubtedly the digestive disturhanoe so frequently present ag- 
gravates the general condition, if indeed it have not been the primary 
source of all the trouble, including the nephritis. By some the re- 
nal condition would be regarded merely as a symptom, by too many 
it is overlooked, from failure to examine the urine. This should be 
a matter of routine in the examination of every patient seen, both 
in office and bedside practice, just as much as the examination of the 
throat, heart, or lungs. Xor should we dismiss the case with only 
one analysis of the urine. These crises are insidious, are apt to run 
an irregular course, and albumen and casts may be absent for ])eriods 
of varying length of time, and unless we follow them carefully, the 
renal condition may escape us to smoulder on and to flare out with 
an acute exacerbation on exposure, e. 7., from invasion of the sys- 
tem by some infectious agent, such as the jmeumoeoccus, streptococcus 
(causing a tonsillitis) or Klebs-Loeffier bacillus. However, if a 
chronic nephritis exist, repeated examinations of the urine will 
sooner or later reveal its presence by the detection of albumen, casts, 
and generally some fatty elements, such as fatty degenerated epithe- 
lium and occasionally fat globules, free or adherent to the casts. The 
casts are hyaline or fine granular, occasionally epithelial. The 
amount of urine varies, is sometimes normal, but reduced with an 
exacerbation of the disease ; the specific gravity is generally lower. 

The following two cases illustrate some of the points mentioned 
above and emphasize the importance of urinary analysis in the affec- 
tions of childhood. The repetition of this point would seem trite, 
yet so much is it disregarded even to the point of criminal negligence 
that the reviser feels that it cannot Ix' too strenuously insisted u})on. 

The first case is that of a boy 19 years old, first seen by me in 
July, 1 89-, and giving the following history: "delicate stomach^' 
since 5 years of age, with flatulence, occasional epigastric distress 
and tendency to constipation, " hip trouble" at 5 years, measles at 7 
years, "la grippe" at 18 years, with marked tonsillar symptoms. 
The urine had never been examined. 

Now for three days, general abdominal pain and tenderness in the 
right iliac region, some nausea, little vomiting, constipation, eleva- 
tion of tem|)erature. 

Physical examination showed a young man well develojwd and 
nourished, face flushed, tongue thick white coat, throat negative. 
CheM, negative. Ahdomenj general tenderness, most marked in the 
right iliac region, no dulness, no mass felt. No cefiema. 

T. lO-J"", P. 84 not otherwise abnr.rmal, K. 20. 
Urine. — High, acid, 1,020, albumen 1 per cent, (single specimen). 
8ecl. slight : little free lat, few blood-corpuscles (normal), occasional 



424 DISEASES OF THE GENITO-URINARY SYSTEM. 

renal cell ; few casts ; hyaline with fat globules and epithelium ad- 
herent, 1 or 2 epithelial ; some of the casts long, others short and 
of laro-e diameter. 

Diagnosis. — (a) Appendicitis, though symptoms may be due to an 
acute exacerbation of a (6) Chronic Parenchymatous Nephritis. 

The subsequent course of the disease showed it to be an appendi- 
citis which went on to recovery without operation. The symptoms 
at first all pointed to appendicular trouble and the urine was ex- 
amined merely as a routine habit and revealed the above condition. 
It had never been examined before, either at the time of the attack 
with measles, with hip-trouble, or with ^^ la grippe" one and a half 
years previous. 

Speculation as to the origin of the nephritis is of course idle. 
These possible causes may have produced it : the attack of measles 
12 years previous, the attack of ^^ la grippe " 1| years previous, or the 
intestinal trouble chronic for 14 years. The last named, if not the 
actual cause, undoubtedly aggravated the renal condition. 

The case continued in my care for about a year, at times the al- 
bumen decreasing to a mere trace, the casts and fatty elements en- 
tirely disappearing, all abnormal elements, however, returning on 
the many indiscretions indulged in. At the end of that time, the 
advice of a " christian " so-called ^^ scientist '' was sought, who 
failed hoAvever to banish the albumen, casts and fatty elements from 
the urine, and in a few weeks he returned to a physician who reports 
that his present condition 3 years later is good, but that albumen and 
casts are still occasionally found in the urine. 

The second case is that of a boy 7 years old, who, coming from out 
of town, presented himself at Dr. Cotton's clinic at the Rush Medical 
School in April, 18 9-. He had had diphtheria the preceding De- 
cember followed by extensive post-diphtheritic paralysis involving 
all the limbs, for which he had received energetic tonic treatment, 
with a diet rich in proteids. Electricity had also been administered, 
but little improvement had been made. In March he had an attack 
of ^^ la grippe,^' a month after which he was brought to the clinic. 
He then was poorly nourished, walked and used upper limbs with 
much difficulty ; no oedema. Heart and lungs negative. The urine 
showed albumen J per cent., fatty renal epithelium, free fat and 
casts, fatty, hyaline and fine granular. The urine had never been 
examined before. The case reported but once at the clinic and has 
never been seen since. 

These two cases illustrate how much we may learn from ordinary 
analysis and to w4iat disastrous results unrecognized renal trouble 
may lead.] 

Treatment. — The patient should be kept in bed and given a fluid 
diet, consisting of milk and whey, with barley water, lemon water. 



AMYLOID DEGEyEBATIOX. 425 

and Imperial drink as boveracros.^ Beef-toa and other broths which 
contain toxic extractives shouUl be excbided. At the be<i:innin<:: of 
the iUness a drastic })nrgative sliouUl be given and repeated in two 
days, a mustard phister or the dry cup applied over the loins, and a 
hot bath triven to promote diaphoresis. Subsequently the wet or dry 
pack adininistereil daily is usetiil, or in more severe eases the hot air 
bath. C'atfeine is to be preferred to dii::italis if there be ;u<^ns of 
cardiac failure, and is useful also as a diuretic. The acetate of am- 
monia and other alkaline diuretics, and the benzoate of soda are also 
of value, but liypodermic injections of piUicarpine sliould be usihI 
with great caution, if at all, in children. When improvement com- 
mencx^s, the patient shcMdd still be kept in bed for several weeks and 
given a Huid diet, of which milk — which has a diuretic action — 
should form a large part. Preparations of iron, either the per- 
' 'ride or the acetate, or the citrate of iron and ammonia, should 
_iven in full doses. The routine use of purgatives with the ob- 
(tf diminishing dropsy is not advisable. Even after the a^dema 
111- 1 albuminuria have quite disappeared the patient should be re- 
g:u\led as an invalid for some months, and should not be allowed to 
run the risks of school life, especially at a public school. Cold and 
damp should be guarded against, and if possible the winter season 
should be spent in a warm climate. Later, a residence at a high 
altitude, es|>ecially if it can be combined with the drinking of a 
chalybeate water, is advantageous. 

Amyloid degeneration of the kidney is generally a part of wide- 

->^''' ad amyloid disease secondary to some condition such as bone 

ise, which is liable to cause prolonged suppuration, but it may 

occur also in the later stages of chronic parenchymatous nephritis. 

The organs are pale, smooth, firm on section, and usually enlarged. 
The cortex is pale and glistening. The glomeruli in which the amy- 
loid change begins are prominent ; the pyramids are of a dark red 
color. 

The urine is increased in quantity, of low sjiecific gravity, pale in 

color, and contains usually .some albumen, often only a trace, and 

hyaline or finely granular d&sts. Dropsy occurs in most cases. It 

**' ts usually the lower extremities, but may Ix' extensive. The 

nt becomes very ana?mic and cachectic, suffers from diarrluea, 

and succumb- usually to asthenia, or to an intercurrent malady. 

The diagnosis must rest on the occurrence of albuminuria and 
polyuria in the course of a disease liable to produce amyloid degen- 

' {^Imperial Drink. 

Cream of Tartar, ^hh 
1 lemon cut in slices, 

White Sii^ar, il'> 

Water, Oiij 

Mix t<^^)gether and let them stand for half an hmir, Appondix.] 



426 DISEASES OF THE GENITO- URINARY SYSTEM. 

eration. Enlargement of liver and spleen will confirm the diagnosis. 

The prognosis is very bad, since amyloid degeneration occurs usu- 
ally in patients whose strength has already been reduced by long 
illness. 

The treatment must be directed, primarily, to the removal of the 
cause and, secondarily, to guarding the patient against chill and 
against accumulation in the blood of toxic products derived from 
the food. 

Congenital cystic disease of the kidneys, a rare condition, is due 
to persistence and abnormal development of portions of the Wolffian 
body. It should be noted, however, that cystic disease of the liver 
may also be present. The cysts vary in size and number, and may 
have produced so great an enlargement at birth as to obstruct de- 
livery. In such cases the infant is still-born, or survives but a short 
time. On the other hand, the enlargement of the kidney may only 
be discovered in middle age. The organs consist of a collection of 
cysts of varying size, and, to the naked eye, may show no appear- 
ance of kidney structure, though this will be discoverable on micro- 
scopical examination. The symptoms ultimately produced are those 
of chronic fibrosis. 

Uric acid diathesis. — It is very common for infants and children 
under the age of two or three years to pass water which quickly be- 
comes turbid from separation of urates, or which is even turbid at 
the time of passing. Such precipitation may be associated with a 
diminished bulk of urine, due to the ingestion of too small a quan- 
tity of fluid, or to an unusual loss of fluid, either by the skin or the 
intestines. Large quantities may appear also during convalescence 
from acute diseases, especially scarlet fever. Such occurrences are 
more or less of an accidental nature, and ought not to be regarded 
as evidences of the existence of a uric acid diathesis. On the other 
hand, the repetition at frequent intervals of these accidents points to 
defects either in diet or in metabolism. There can be no doubt that 
children of gouty parentage are particularly liable to such attacks, 
and that in addition they on some occasions pass uric acid crystals. 
Whereas the passage of urates may give rise to no symptoms, it is 
otherwise with uric acid. 

Sir William Roberts enumerates, as the conditions favoring the 
separation of uric acid from the urine, high acidity, a small amount 
of pigmentation, poverty in salines, and a high percentage of uric 
acid. In infants the quantity of pigment is small, and the percent- 
age of uric acid is said to be high as a rule, or as a frequent incident. 
When, therefore, there is added to these conditions an undue acidity 
of the urine, three of the four main factors of the precipitation of 
uric acid in the urinary passages Avill concur. In older children, 
especially among the poor, who live largely upon cereals, the fourth 



i 



CALCULUS. 427 

factor — poverty in salines — may also bo ])rosont. The separation of 
the uric acid may occur at any ])art of the urinary tract, in the ter- 
minal straight tubules of the kidney, in the pelvis, the ureter, or the 
bladder. In a typical attack, the child rather suddenly becomes 
restless and peevish. It screams when touched, and it may be pos- 
sible to detect some tenderness in both lumbar regions. Micturition 
is fre(|Uent and attended by pain. The urine deposits uric acid, 
which may be recognized as a cayenne pepper deposit in the vessel, 
or as red stain on the napkins. The external orifice of the urethra 
is red and excoriated, and in girls there may be much irritation of 
the vulva. In boys with phimosis, balanitis may l)e j)roduced with 
much (edema of the surrounding tissue. The attack subsides in a 
few days, but similar attacks are very apt to occur until the child 
reaches two or three years of age. For the next two or three years 
of life the liability to such attacks appears to be less, but after five 
or six years old they again become frequent, and the irritation pro- 
duced by the presence of uric acid in the urine is one of the causes 
of enuresis. 

The etiology of the condition is somewhat obscure. The attacks 
may be determined by the ingestion of too liberal a diet, by want of 
exercise and fresh air, especially during winter months, when chil- 
dren are much confined to the house, and they are favored by too 
small a fpiantity of fluid in the diet. Such attacks occur not only 
in children who inherit the gouty diathesis but also in those of stru- 
mous tyjie. 

Calculus in the pelvis of the kidney is not very rare in childhood. 
It usually consists of uric acid, more rarely of oxalate of lime. It 
may produce few or no symptoms, though there may be blood in the 
urine, which in older children may give to it a well-marked dee]) 
red color. In infants a stain of bright blood is noted on the na))kin. 
Renal calculus is said to be the commonest cause of hicmaturia in 
infants. In other cases the irritation of the stone may eventually 
induce suppurative pyelitis. Infants may suffer from true renal colic. 

(Tiblx)ns, who has given an excellent descrij)tion of this condition,' 
has met with it only in private practice and in the children of gouty 
parents. The symj)toms are pronounced, though the diagnosis is 
often difficult. In the midst of apparent health, it may be during 
sleep, the child is seized suddenly with acute alnlominal jiain, ac('(>m- 
panied |X'rhaps by vomiting. The temperature may be normal or 
raised 2° or 3° F. It resents any disturbance or examination, lies 
persistently on one side, and it may be possible to ascertain that the 
loin on the opjxisite side is acutely tender. Af\cr a time the child 
may iK'come prostrate, or even collapse^l. The attack subsides in 
fri.m one to two days, and convalescence is rapid. .Similar attacks, 
^ Medico-Chirurrjical Trans., vol. Ixxix., p. 41. 



428 DISEASES OF THE GENITO-UBINARY SYSTEM. 

to the number of three or four, may occur at intervals of a few weeks 
or months. During the attack the legs are drawn up and the thighs 
flexed upon the abdomen. One or both testicles are retracted. (Five 
out of six of the cases recorded by Gibbons occurred in boys.) The 
urine passed during the attack is clear, but contains a trace of albu- 
men, and, under the microscope, free blood cells and crystals of uric 
acid. After the attack the urine may contain large quantities of uric 
acid, either in detached crystals, or in small masses aggregated to- 
gether by mucus. 

If a calculus reach the bladder it may be passed by the urethra. 
This, as might be expected, occurs more often in girls than in boys. 
In boys, the calculus may become impacted in the urethra. If re- 
tained in the bladder, it gives rise to frequent painful micturition, 
arrest of the stream, passage of blood at the end of the act, pulling 
of the prepuce, and other ordinary symptoms of vesical calculus. 

The treatment of excessive excretion of uric acid must depend 
upon a recognition of the cause and the nature of the symptoms. 
The frequent passage of uric acid in the free crystalline state should 
direct attention to the diet and the condition of the digestive organs. 
It may be possible, by diminishing the amount of proteids, if this be 
excessive, to remove the cause, or it may be found that the child is 
suffering from acid dyspepsia, due, perhaps, to fermentation of an 
excessive quantity of carbohydrates. The administration of alkaline 
medicines, which will be desirable during the attacks, should not be 
continued in the hope of warding them off. In infants, a deficient 
amount of fluid in the diet is not likely to be a cause of the deposi- 
tion of uric acid, but in older children an increase of the fluid taken 
may serve to prevent attacks. Renal colic should be treated by 
giving a warm bath, followed by a poultice to the loins, and the ad- 
ministration of a mixture containing compound tincture of camphor, 
ammonium bromide, and lithium carbonate. If any doubt exists as 
to the possibility of the presence of vesical calculus, the bladder 
should be sounded carefully, and, if the symptoms persist, the ex- 
amination should be repeated. 

The prophylaxis of the consequences of the uric acid diathesis is 
important. The child, if an infant, should be well clothed, taken 
out into the open air daily, and the diet regulated to avoid dyspep- 
sia. To older children the same remarks apply, with the addition 
that they are benefited by taking as much exercise as possible, short 
of over-fatigue. 

Hydronephrosis. — Dilatation of the pelvis of the kidney caused 
by accumulation of fluid may be conr/enital and due to defect in de- 
velopment of the ureter or urethra. The dilatation at birth may be 
so great as to produce a distension of the abdomen, which obstructs 
delivery. In another form the dilatation affects the pelvis and 



PYELITIS. 429 

ureters, but there is uo obvious obstruction. lu such cases the dila- 
tation is moderate, and the patient may survive for some years, but 
eventually succumbs, usually to purident infection of the dilated 
parts. 

Intermittent hydronephrosis nuiy be met with in children. Un- 
easiness or an attack oi^ ]>ain in one or other Hank is found to be as- 
sociated with the development of a tumour in the kidney re-iion, 
■Nvhich may attain a larirc size and then suddenly dis:\pj)ear, its dis- 
appearance being attended by cessation of the pain and the passage 
of a large (piantity of pale urine. 

Actjuiral Jn/droncjfhrosis is not conunon in children. AVhen of 
mmlerate size, it is usually possible to recognize that the tumour 
formed by hydronephrosis is renal, but it may be difficult to say 
whether it be due to sarcoma or 'Huid. When somewhat larger, so 
that it reaches to the middle line, the question of retro-peritoneal sar- 
coma will arise, and the question may only be possible of solution 
by puncture, which, in hydronephrosis, yields a clear, faintly yellow 
fluid, containing urea and uric acid in small quantities. When it is 
considered necessary to make a puncture, the needle should be in- 
serted over the tumour posteriorly, midway between the iliac crest 
and the twelfth rib. The best treatment appears to be by incision 
in the lumbar region and drainage. The treatment of intermittent 
hydronephrosis is not settled. When associated with movable kid- 
ney, as is sometimes the case, a properly adjusted pad to keep the 
organ in place may give nuich relief. Movable kidney, however, is 
very uncommon in childhood. 

Pyelitis is in children due usually either to stone or to tubercle, 
but it occurs occasionally in the course of specific fevers, and is met 
with, in rare instances, without any discoverable cause. It is also 
occasionally secondary to perinephritis. The symptoms, if the 
affection occur in the course of a specific fever, are not very dis- 
tinctive, and, unless the urine be examined, will probably be over- 
lookecF. The urine may be smoky from the presence of l)lood. The 
amount of pus present varies, and it may even disaj)pear for a time 
owing, proV)al)ly, to temporary- blocking of the ureter. In uncom- 
plicated cases there is intermittent fever, the exacerbations being ac- 
companied by rigors, so that the case may resemble malarial fever. 
The child looks ill and, if the condition persists for some weeks, 
brr-omes much emaciated and exhausted. There is tenderness in 
flank, and enlargement of the kidney may be demonstrable; 
f ventually great distension of the renal pelvis may occur. In the 
treatment of this affection, astringents appear to be of no use, and 
the best course is to give the jiatient large quantities of water con- 
taining a little citrate of jK^tasli, or some of the milder alkaline mineral 
waters to drink. When the enlargement is sufficiently great to 



430 DISEASES OF THE GENITO-URINARY SYSTEM. 

allow a distinct tumour to be made out, or, if the general symptoms 
are persistent and severe, the kidney should be explored. 

Perinephritic abscess. — Inflammation and suppuration around the 
kidney may be the resnlt of injury, or of extension of inflammation 
from the pelvis or ureters, or from the appendix, spine, or pleura. 
In other cases, the condition occurs as a complication or as a sequel 
of acute infectious diseases ; but in a considerable number of cases 
no cause can be discovered. The inflammation produces a large, 
ill-defined swelling in the flank ; the swelling is very tender, and 
there may be much pain, which is greatly aggravated by movement. 
The patient keeps the thigh flexed, and there may be a considerable 
resemblance to early hip-joint disease. It will be found however 
that with the hip flexed gentle passive movement of the joint does 
not cause pain. The formation of pus is attended and followed by 
irregular fever, rigors, and sweats. The only treatment which can 
relieve the patient is incision and drainage; the operation should 
not be too long delayed as the pus may track downwards into the 
groin, or the abscess may rupture into the peritoneum, bowel, bladder, 
vagina, or even into a bronchus. 

Tumours of the kidney, though rare at any age are more common 
under six years of age than subsequently, and are probably the 
form of new growth most often met with in the abdomen in children 
under that age. Their pathology is obscure, but they are probably 
in all cases congenital. Adenomata may be met with, but as a rule 
the growths are sarcomata or rhabdo-myomata, that is to say, round- 
celled sarcomata containing striated muscular fibres. In most cases, 
the first symptom to attract attention is enlargement of the abdomen, 
which is found to be due to a tumour in the lumbar region. It is at 
first, as a rule, freely movable on palpation, but is little affected by 
respiration. It has a smooth, rounded or indistinctly lobulated sur- 
face, and when soft and of very rapid growth may fluctuate. Hsema- 
turia is present in about one-third of the cases and may be the 
earliest symptom. The urine contains clots of blood which some- 
times have the form of casts of the ureter or pelvis ; their passage 
produces attacks of colic. The growth of the tumour, which may 
attain an enormous size, is attended by rapid emaciation. An im- 
portant point in the diagnosis of all renal tumours is the fact that 
they are traversed by the colon, which usually yields a tympanitic 
note ; when, however, the enlargement is great, the gut may be so 
much compressed that this sign is wanting. If the case be seen 
early, renal may be distinguished from retro-peritoneal sarcoma by 
the fact that the latter at first forms a tumour in the middle line and 
is not movable ; but at a later stage it may be impossible in the 
absence of hsematuria to make the distinction. An enlarged spleen 
is more movable than a renal tumour, moves freely with respi- 



TUBERCULOSIS, 431 

ration, and presents usually a sharp edge and notch. On the right 
side, tumour of the kidney may present some resemblanoe to tumour 
of the liver, but mav be distiuouished bv the sliohter movement 
with respiration, and, as a rule, by a band of resonance between it 
and the lower edge of the ribs. Abscess or tuberculous disease of 
the kidney usually causes pus in the urine and pain and tenderness 
in the lumbar region. 

TuberciUosis of the kidney, except as a part of a general tuber- 
culosis, is rare in childhood, but cases occur occasionally in which 
tuberculous pyelitis of chronic type is met with, and leads to dis- 
organization of the kidney. The course in such eases is very insid- 
ious, and pain may only be com]>lained of when the pelvis has 
become distended with purulent and cheesy matter ; an enlargement 
of the organ may then be detected, and, as a rule, the urine contains 
albumen and pus. If the ureter becomes blocked, pyonephrosis 
ensues, and a fluctuating tumour forms. In such cases, the tempera- 
ture is hectic, and the symptoms can only be relieved by operation. 
The occurrence of symptoms of pyelitis accompanied by hemorrhage 
points rather to stone in the kidney. Short of operation, which is 
rarely called for in children, treatment should be directed to render- 
ing the urine as unirritating as possible, and for this purpose a milk 
diet is the most efficacious. 



» 



CHAPTER XXXVII. 
DISEASES OF THE NERVOUS SYSTEM. 

The Nervous System in Infancy — Night Terrors — Headache — Stammering and 
Stuttering — Alalia — Deaf -Mutism ; Forms ; Causes ; Prophylaxis ; Treatment. 

The nervous system at birth has not attained its full structural 
development, and its functions are imperfectly developed. The brain 
is large at birth in relation to the size of the body generally. After 
birth it grows in bulk w^ith great rapidity, and the convolutions be- 
come more complex and the sulci deeper. This period of very rapid 
growth terminates about the seventh year, and thereafter the increase 
in bulk is much slower. The spinal cord is slender, and the pyram- 
idal tract very imperfectly developed at birth. 

The special characteristic of the movements performed during the 
earliest infancy is the want of coordination. The main exception is 
the act of sucking, which is perfectly performed within the first 
three days of life, and is therefore regarded as an instinctive move- 
ment. The act of grasping is also apparently instinctive. The re- 
flex movements gradually become more numerous and complicated ; 
thus sneezing and coughing may be performed at birth, but tickling 
does not produce smiling until the end of the second month. The 
skin reflexes are present at birth, and the tendon reflexes (knee-jerk) 
also, as a rule. The infant also performs certain spontaneous move- 
ments — crowing, crying, kicking, and waving its arms from an early 
age. They are apparently elicited by general " large ^\ somatic sen- 
sations of comfort or discomfort. The power to coordinate volun- 
tary purposive movements is acquired slowly. Thus grasping is 
first performed as a voluntary act about the fourth month, at which 
age both instinctive and voluntary grasping may usually be elicited 
in succession in the same child. Voluntary grasping movements are 
at first very irregular and imperfect. The infant is also handicapped 
in its effort to grasp an object by inexperience in judging distance. 
Accommodation is imperfect, and the coordination of the ocular 
muscles is not complete, so that irregular movements often occur 
during the first few wrecks of life and produce transient squint. 
This squinting is particularly apt to occur on awaking from sleep. 
During the first two years of life the child is undergoing an ex- 
tremely rapid process of education. It learns to distinguish objects 

432 






DISEASES OF THE yERVOUS SYSTEM. 433 

bv taste, sight, and touch : it k^u'iis to distinguish between animate 
and inanimate objects, and to know certain individuals. It learns 
to judge distances, to grasp and pull with appropriate force, to walk, 
and to speak. For the next two years education is only a little less 
rapid. The brain of the infant and child then are in a continuous 
state of active development and, during waking hours, of intense 
functional activity. Owing to the imperfect development of the in- 
hibitory and regulating apparatus, the response is out of proportion 
to the strength of peripheral stimuli, and the area of response is apt 
to be unduly wide. 

In the sphere of the emotions there is a similar want of control. 
The intellectual processes are slow, and the ix)wer of discriminating 
between the objective and subjective imperfect. This is well ex- 
emplified in the night terrors (pavor nocturnus), so common in child- 
ho(xl, especially in neurotic children, or those habitually subject to 
over-excitement. The condition is closely analogous, if not identical, 
with nightmare, and of those vague feelings of fear which make 
many adults dread to pass a churchyard by night — that instinctive 
and therefore unreasoning dread of darkness doubtless inherited from 
remote ancestors, which makes " two o'clock in the morning courage '' 
the highest form of that ancient virtue. Most children dislike the 
dark, and dread being set to go to sleep in a dark room. In chil- 
dren subject to night terrors this feeling is greatly exaggerated. The 
attack of pavor nocturnus generally begins from one to three hours 
after falling asleep.^ The child wakes up suddenly with a shriek or 
loud cry, and appears much alarmed. It seems to have visual, more 
rarely auditory hallucinations, and, though not completely uncon- 
scious of its surroundings, it does not recognise the jiersons about it. 
The heart is found to be acting violently, the pulse is rapid, the 
limbs tremulous, and the body is covered with sweat. In a few 
minutes, or perhaps only after half an hour, it begins to grow calm, 
loses its hallucinations, recognises those about it, and soon falls into 
a sleep, which usually lasts undisturbed until morning. Occasionally 
such attacks occur by day if the child fiill asleep. Children who 
suffer in this way are always of neurotic type, usually have a neurotic 
parentage, and often have dyspepsia or chronic diarrhoea. The 
liability to pavor nocturnus begins in the second year, and is rather 
Iter in the male than in the female sex. The attacks gradually 
'•me less frequent and generally cease altogether about twelve years 
of age. In a few cases the patients have become epileptic, but this was 
probably no more than a coincidence. Children liable to these at- 
tacks .should be treated with the greatest consideration. They 
should not V)e comjKlled to go to bed in the dark, and they should 
Ti^'^ be frightened by silly stories of the supeniatural, in which some 

' Braun, Jahrb. /. Kinderhkde., Bd. xliii., S. 406. 

28 



434 DISEASES OF THE NERVOUS SYSTE3L 

nurses delight. They should get enough sleep ; very often it will be 
found that they are allowed to sit up late. They should be carefully 
dieted, and in particular any imperfection in the digestive processes 
should be corrected. In some cases there is marked constipation or 
irregular action of the bowels, with occasional periods during which 
the stools are fluid and very offensive. In such cases attention to 
the diet and the use of antiseptic drugs internally (see p. 387) will 
prevent the recurrence of the night terrors. Sedative drugs seldom 
have much influence in preventing the terrors, and opium is dis- 
tinctly contra-indicated. 

Headache is not a common symptom in infants or young children, 
and when its presence can be established it will be found, in many 
cases, to be due to disease of the ear, cranium, meninges, or brain. 

Children may suffer from toxic headache due to ill-ventilated 
rooms — one variety of morning headache is due to this cause — or to 
absorption from decomposing material in the intestinal canal. There 
is also that large class of toxic headaches, which are to be observed 
frequently at the onset of scarlet fever, measles, typhoid fever, and 
other acute diseases. Mistakes, however, are not likely to occur in 
such cases. It is otherwise with the headache produced by error of 
refraction. Of these the most important is hypermetropia ; it comes 
on in the morning as soon as the eyes are opened, but wears off if 
the eyes are not used for near work. Reading or sewing makes it 
worse. It appears to be due ^ to spasm of accommodation. During 
sleep the ciliary muscle is at rest, but upon opening the eyes in the 
morning it is thrown into strong action, and the suddenness of the 
transition causes pain. When, after a time, adaptation takes place 
the pain diminishes, only to increase again if a fresh call is made on 
accommodation by near work. The pain, which is accompanied by 
superficial tenderness, is referred to the mid-orbital area, which is 
situated over the centre of the eyebrow and includes a greater part 
of the upper lid. The longer the strain the larger the part of the 
area involved, and when most developed the pain may be referred 
also to an area higher up, at a point about the margin of the hairy 
scalp in a vertical line above the eyebrow area. The patient states 
that the pain is " over the eyes '' or ^' in the eyes,^' and, to point it 
out, places the right hand across the forehead, touching the centre of 
the right eyebrow with the hypothenar eminence, and the centre of 
the left eyebrow with the tips of the fingers. For this reason the 
headache has been spoken of as '^ frontal,'^ but if an intelligent 
patient is told to point out the painful areas with both hands, he 
places the tips of the fingers just above each eyebrow. 

The combination of astigmatism with hypermetropia increases 
greatly the liability to headache. A robust child may have a good 
' Head, Brain, vol. xvii., p. 339. 



STAMMERIXG. 435 

deal of hypermetropia (-f 3d) without headache, wlierens an astio- 
matie error of -f- 1p may produce definite pain and tenderness. De- 
terioration of general healthy and '' tone " niay, even in simjile 
hypermetropia, be followed by headache. Myopics, after long use 
of the eyes, may complain of an ill-detined, tired, aching feeling in 
the forehead ; but myopia, especially in children, is not of any im- 
portance as a source of headache, except in th(^ rare cases in which 
it is complicated by spasm of accommodation. Headache in thi: sit- 
uation, which is worse in the morning and aggravated by close work, 
- oially in a child who has recently lieen set to much reading, writ- 
_. and sewing at schtx>l, should raise the sus])icion of Iiypermetroj)ia. 
Paralysis of accommodation by atropine will remove the headache, 
and will also serve as a necessary preliminary to the estimation of 
tlie error of refraction. 

A common cause of pain referred to the side of the head and neck 
is otitis media, but this may also cause pain towards the vertex, and 
in the parietal regions if there be a rise of tension in the middle ear 
such as takes place Ix^fore the drum is perforated. A common cause 
of dull, heavy pain in the frontal region is the presence of adenoids 
in the naso-pharynx. Headaches from anji^mia are not very common 
in children, but in girls of the rheumatic diathesis they occur rather 
frecpiently, and are sometimes the precursors of chorea. True megrim 
is a rare affection in childhood, but headaches associated with the 
presence of the uric acid diathesis are common, and unless their real 
nature l)e recognized are apt to be intractable. Many jiatients Avho 
would be cured by a dose of calomel, or a short course of magnesium 
sulphate, go on for years taking bromides, phenacetin, and other 
hvpnotics with only temporary relief. 

Stammering and stuttering are due to a want of regular con- 
traction and coordinated action among the muscles concerned in artic- 
ulation. This imi>erfection may exist only in the lips, interfering 
with the production of the explosive consonants {bjp, dy (, hard r/, and 
r the tongue may \)e involved so that there is hesitation in the 
liiction of the continuous consonants (r,f, f/i, r, x, .s7j, y, ?/•, ?», ?j), 
or again there may be laryngeal spasm causing difficulty in the pro- 
duction of the vowel sounds. To these ccmditions some would limit 
thp term Mammemuf, and would aj)ply the term sfuttenuf/ only to 
- • more distressing cases in which, in addition to the affection of 
neuro-muscular mechanism of articulation }>ropcr, the resj)iratory 
muscles are involved. 

Defects of speech of this ty|X? are often hereditary, or they occur 
in families in which one or other parent is distinctly neurotic. As a 
nile the defect does not become marked until after the age of three 
or four years. Sometimes it is perceived first after a severe febrile 
illness (infectious fevers), occasionally it is associated with chronic 



436 DISEASES OF THE NERVOUS SYSTEM. 

naso-pharyngeal affections and is improved after the local condition 
has been treated. A mild degree of stammering may be produced 
by imitation, and cases are sometimes met with which are hysterical, 
or in which the liysterical element counts for much. 

Difficulty with the explosive consonants is the commonest form, but 
both this and other forms only become serious affections when com- 
bined with irregular action of the muscles of respiration. In such 
cases, during the attempt to breathe, spasm of muscles of the face, 
arms, and trunk may occur and increase greatly the distress which 
the patient suffers. 

The essential point in treatment is to give the child regular and 
systematic instruction in breathing and articulation, by exercises re- 
peated many times a day. Considerable skill and much patience are 
demanded, and it is best, if possible, to commit the child to a teacher 
with special experience and aptitude for such work. The difficulty 
in speech is usually absent during singing or intoning, and in slight 
cases ordinary singing lessons, if the teacher give attention to the 
breathing, will often suffice to produce great improvement. On the 
other hand, the individual may learn to sing and intone well, although 
no improvement has taken place in the speaking utterance. 

Cases are occasionally met with in which the child, though appar- 
ently well developed and intelligent, does not acquire the art of 
speech. This condition of alalia idiopathica may be due to struc- 
tural defect of development, and be permanent. It is then associated, 
as a rule, with other evidences of idiocy. But it is not uncommon 
to meet with children who, up to the age of three or four years, 
make little or no effort to articulate. This retarded development is 
a source of great anxiety to the parents. The diagnosis may gener- 
ally be made without much difficulty by observing the general aspect 
and habits of the child, who learns to play and to walk like other 
children. Such children when they begin to utter articulate sounds 
learn to speak with great rapidity. A child Avho reaches the age of 
two or three years without attempting to speak should receive regu- 
lar instruction for short periods several times a day. 

Aphasia due to organic disease may occur in childhood and 
presents the same characters as in the adult. The prognosis is, 
however, better (see p. 87). 

[• Deafness may exist in any degree from mere " hardness '' or 
dullness of hearing to total loss of the sense. Any degree of deaf- 
ness great enough to prevent the human voice, used in the ordinary 
manner, from being heard will, if it be congenital, or developed in 
childhood, render the child a deaf-mute, unless this result be pre- 
vented by special education. The term surdism is applied to those 
degrees of deafness which make " the acquisition of speech in the 
very young impossible by ordinary means, or which involve the loss 



DEAFXESS. 437 

of recently acquired speech."^ Deaf-mutism is rather more common 
in many boys than girls. 

Few deaf-mutes are totally deaf A large vibrating tuning-fork 
in contact with the cranium is heard by almost all. Aerial sounds 
— for instance, a tuning-fork at a short distance — are heard by all 
but about 10 per cent. Hearing for speech to an extent sufficient 
to be of use in teaching exists in about 25 per cent, of deaf-mutes. 

About half the deaf-mutes are deaf from birth. Deaf-mutism may 
undoubtedly be hereditary. Thus to a deaf-mute parent (father or 
mother) may be born some hearing and some deaf children, or a 
deaf-mute child may be born to hciiring parents if one belong to a 
family in which congenital deafness has occurred in previous gener- 
ations, even though not in the direct line. In other flimilies deaf- 
mutism is one term of a series of nervous defects, such as idiocy, 
insanity, or epilepsy, with which various members are afflicted. Con- 
sanguinity increases the liability to deaf-mutism in the offspring," and 
is more potent in this respect than the marriage of deaf-mutes, since 
in one parent the deafness may have been acquired. Unions between 
deaf-mutes are commonly not prolific, and are often sterile. 

Congenital deafness may be due to impcrfecf development of the 
organ of hearing. Thus malformation of the auricle may be associ- 
ated with almost entire absence of the structures of the internal ear. 
But either the middle or the internal ear may be affected indepen- 
dently of the other. Tn other cases, probably the majority, the 
deafness is due to inflanimation of the interual ear either before birth 
or shortly after, ending in bony overgrowth and destruction of the 
nervous mechanism. 

Acquired deaf-mutism is due, in the majority of cases, to inflam- 
matory disease which has spread from the middle to the internal ear, 
and caused destruction to the membranous labyrinth, and the nervous 
structures in relation with it. In other cases the inflammatory mis- 
chief has extended from the cranial cavity, and in a few the lesion 
producing deafness is a primary inflammation of tlie labyrinth. In 
any case if the disease which causes deafness occurs before the age 
of six or seven the child is likely to become mute. The liability 
will be increased if the disease which causes the deafness lias pro- 
duced also other changes which have lowered the general intelligence ; 
it will Ije diminished if the child has already possessed fair powers 
of speech, and if well-directed efforts are made to train the child to 
retain and extend the powers it previously possessed. 

' "Deaf-Mutism," by J. Kerr Love, M.D., and W. H. Addis^.n, A. ('.P., Glas- 
K-'W, ]K%. This is an excellent study r»f the sul»jeot. 

'According' to statistics siid to have Wi-n c(.llecte<l l)y Liehreich, there were in 
Xa.sKiu amonjj the Roman Catholics, who forbid consanguineous marriages, one deaf- 
mute to 1,307 pers<^)ns living, while among the Jews, who encourage such marriages, 
there was one deaf-mute t*» 508. 



438 



DISEASES OF THE NERVOUS SYSTEM. 



In Great Britain deaf-mutism dates from an attack of scarlet fever, 
measles, typhoid fever, or whooping-cough in 44 per cent, of all 
cases of acquired deafness ; scarlet fever is alone responsible for 23.5 
per cent. Next in importance to the infectious fevers stands menin- 
gitis and various diseases of the brain (23.9 per cent.). Falls and 
other accidents are held responsible for nearly 9 per cent. In 
America and on the Continent of Europe the ratios are different, 
owing in part to the fact that an unusually large portion of children 
attacked by epidemic cerebro-spinal meningitis, a disease very rare in 
Great Britain, become deaf. 

Prophylaxis. — The prevention of the more serious consequences of 
otitis occurring as a complication of the acute exanthemata is there- 
fore of great importance in this connection. The necessity for the 
early systematic treatment of otitis from other causes is also great, 
since a case which may be amendable to treatment in the early stage 
may be most intractable after the chronic inflammation has persisted 
for three or four years. 

Treatment directed to the naso-pharynx, the removal of adenoid 
vegetations when they interfere with the ventilation of the middle 
ear through the Eustachian tube, and of enlarged tonsils is also re- 
quired in many cases, for every effort should be made to improve 
such power of hearing as the child may have. Search should be 
made for any obvious cause of deafness, otorrhoea, adenoids, etc., in 
order that the condition may be treated in the hope that hearing 
may be so far improved that the child may be, in part at least, in- 
structed through this sense. The education of deaf-mutes is now 
compulsory both in England and Scotland. There is much differ- 
ence of opinion as to the best method of education. For those 
children who possess a sufficient remnant of hearing to be instructed 
through the human voice there can be little doubt that this method 
should be employed as much as possible. For those who have no 
useful hearing the so-called oral system is the best, if they possess 
sufficient intelligence. Under it the pupil learns to understand 
speech by watching the movements of the lips, and acquires the 
power of speaking with more or less distinctness. With those who 
possess some hearing power the two systems — the acoustic and the 
oral — may be combined. There can be little doubt that many deaf- 
mutes, whether the defect be congenital or acquired, are of a low 
order of intelligence. Many are of average intelligence, and a few 
possess very superior abilities. When the child does not possess 
sufficient quickness to acquire the art of lip-reading, it may yet 
learn to understand others, and to express itself by means of the well- 
known hand signs, and the power of using this system is a useful 
possession for all deaf-mutes. The education of a deaf-mute should 
begin at about seven years of age, and the oral system requires a 



DEAFSESS. 439 

course of instruction extending over ten years. The teachers must 
undergo a special training,^ and be endowed with much patience. 
The more individual attention the teacher can give the better the 
result. 

1 There is a training oolleire for teaohei-s at Ealing, Middlesex, and also at Fitz- 
roy Square, London. There are 31 public schools for deaf-mutes in England and 
"Wales, with (in 1S95, according to Li>ve and Addison) 2,030 pupils, 10 in Scotland 
with .324 pupils, and 4 in Ireland with "i47 pupils. According to the returns of the 
census of 1S91 there were nearly 20,000 deaf-nmtes in the United Kingdom at that 
time. If the children under live, in whom the defect has not yet been recognized 
are addeil, it is estimated that the number would be about 22,000. The proportion 
to the general population appears to be decreasing slowly. 



CHAPTER XXXVIII. 
HYSTERIA: PICA. 

Hysteria : Definition ; Somnambulism ; Delirium ; Paralysis ; Neuro-mimesis ; 
Fasting Girls — Diagnosis of Hysteria — Treatment — Pica or Dirt Eating. 

Hysteria is a psycho-neurosis. It is the manifestation of a special 
form of degeneration traceable to the influence of heredity. As 
Donkin has well said/ ^'it must be remembered . . . that some 
degree of mental disorder, evinced in the sphere of feeling rather 
than of intellect, colors and underlies all its phenomena, predomi- 
nantly psychical in expression though they often are.'^ 

Somnambulism, which is relatively common in childhood, espe- 
cially in girls, is, I believe, usually, if not always, an hysterical phe- 
nomenon. This opinion, advanced by Gilles de la Tourette,^ and 
accepted by Charcot, is supported by, among other considerations, 
the facts that the somnambulistic state is often preceded by slight 
convulsions, and that somnambulistic children at a later age in many 
cases show distinct signs of the hysterical constitution. The patient 
while in the somnambulistic state performs purposive acts as well as 
when awake, or with even greater sureness and dexterity, but on re- 
turning to the normal state has no memory of these acts. The func- 
tions of the higher centres concerned in consciousness are suspended, 
but those of the lower automatic centres are in full activity. Som- 
nambulism begins usually during sleep, whence its name. The 
similarity between somnambulism and the post-epileptic automatic 
state will not escape attention. The parallelism between epilepsy 
and certain manifestations of hysteria is indeed so remarkable that 
it often creates great difficulty in diagnosis. 

A common manifestation of hysteria in childhood is delirium pre- 
ceded or not by distinct convulsions, and generally accompanied by 
struggling, biting, kicking, crying, shouting, etc. In some cases 
there is a well-marked tonic stage, and opisthotonos may be produced. 
There does not appear to be complete suspension of consciousness, 
but the assertion of the patients that they have not any accurate 

1 ** Diseases of Childhood (Medical ). " London : 1893, p. 310. Those who would 
pursue this subject furtlier cannot find a more trustworthy guide through the laby- 
rinth than the article by the same author in Tuke's "Dictionary of Psychological 
Medicine." 

2 " Traits de 1' Hysteric," sec. part., t. ii., p. 300. 

440 



PARALYSIS. 441 

recollection of the incidents of their attack is probably true. The 
delirious state may last for a few minutes, for hours, or days, and 
when long lasting is commonly succeeded by a stage of depression. 
At the moment of onset there is a sudden pallor, but later the face 
is flushed, often perspiring ; afterwards it wears a dull, heavy ex- 
pression, and there is usually some congestion or actual cyanosis. 
During the delirious state choreiform movements may be conspicu- 
ous, and may persist for some days. The subjects of attacks of this 
nature, usually girls of eight or nine years old and upwards, are 
often bright and intelligent, but excitable and emotional, and some 
emotion such as a disappointment or an injustice, real or fancied, at 
school, is commonly an immediate antecedent. 

Paralysis is rare in childhood, and commonly there is only par- 
tial loss of power in the parts affected. Hemiplegia, monoplegia, 
and paraplegia have Ix^en observed. The onset may be sudden after 
convulsions, but is usually gradual. The duration is very uncer- 
tain, and the palsy may disappear suddenly or gradually under the 
influence of some new emotion, or of some fresh circumstance which 
calls the will into exercise. Paralysis, if pei-sistent, is usually ac- 
companied by contracture, and when this has lasted for some time 
the tendon reflexes l)ec()m{' exaggerated and there may even be ankle 
clonus, unless the rigidity be very great. Contractures of the mus- 
cles of the leg may produce various forms of talipes, usually sym- 
metrical. Hysterical aphonia may occur in young girls, the patient 
sj)eaking in a whisper, or the child may refuse to attempt to speak 
(mutism). In other cases again there are recurring spasms of the 
respiratory muscles, leading to the utterance of curious coughs, cries 
and grunts ; while in some there is obvious mimicry, as of the bark 
of a dog. Anaesthesia is rare, but not so hypenesthesia. PTcadache 
\^'ith suj>erficial tenderness of the scalp is not uncommon, and other 
skin areas may Ix? exquisitely tender. A combination of tender- 
ness of joints with paretic contracture may produce a condition 
resembling arthritis, and occasionally the joints are swollen a« 
well as tender. The hip is the joint most often affected, apparent 
ghortening of the limb being produced by tilting of the pelvis. Dis- 
ease of the knee joint also may be mimicked, or there may be marked 
spinal tenderness with curvature. So also peritonitis or pleurisy 
may be simulated, but in using that term we must assume that the 
mimicry is beyond the control of the child's will, though there may 
exist in oonsciousness a knowledge that by a stronger effort of the 
will the disturbance of function would pass away. Further, it must 
be remembered that the diseased condition may really exist to a very 
slight degree, the painful sensations accompanying it being greatly 
^•vnggerated, and combined with distinct hysterical manifestations. 

In some cases the api)etite for food is extremely capricious, less 



442 HYSTERIA: PICA. 

and less is taken, until finally, under injudicious management, all is 
refused. Of such are the ^'fasting girls,^^ in whom catalepsy is 
readily produced. Even when food is taken it is often rejected by 
vomiting, and the patient may be reduced to the most extreme de- 
gree of emaciation. It is obvious that in such cases the mental dis- 
turbance is so great that the patients must be considered, at the least, 
on the border land of insanity. 

The diagnosis of hysteria should only be made after organic dis- 
ease has been excluded, and it must be remembered that in a case 
presenting hysterical symptoms there may be slight organic disease, 
the subjective symptoms of which are greatly exaggerated. In many 
cases the inconstancy of the symptoms, in distribution and in intensity, 
will assist diagnosis. In all a full consideration must be given to the 
surroundings of the patient, and particularly to the psychical char- 
acteristics of the mother. If joint disease or abdominal tumour be 
simulated it may be necessary to anaesthetize the patient, though here 
also the possibility of the existence of organic disease in a minor de- 
gree must not be lost sight of. 

The treatment should be guided by the view that in hysteria we 
have to combat an imperfect or perverted nutrition of nerve cells 
predisposed by heredity to irregular activity. Means should be 
taken to improve the general nutrition by a sufficient diet contained 
in meals taken at regular times, by residence in the country, outdoor 
exercise, and so on, while the child should be removed as far as pos- 
sible from the influence of fussy and emotional relatives and placed 
under the control of instructors who will know how to guard against 
over-pressure and over-excitement. In the poorer classes it is well 
to enlist the father to exercise the needed firmness and kindness, for 
the mother is apt to alternate rather than to combine these two essen- 
tials. In severe cases hospital treatment often works wonders, for 
nowhere can that course of treatment which Donkin has happily de- 
scribed as " observant neglect " be better applied. In the richer 
classes a modified Weir-Mitchell treatment in a suitable home should 
be recommended. In minor manifestations, such as hysterical cough, 
a good teacher of elocution who makes the patient breathe and speak 
on a system will often effect a rapid cure. The routine use of seda- 
tives, such as the bromides, is strongly to be condemned. They 
should be prescribed only in emergencies, or when there is ground to 
suspect that fits are sometimes, or in part, epileptic. Tonics, iron, 
and cod-liver oil are useful adjuncts to treatment by diet and moral 
suasion. 

Pica : dirt eating, earth eating. — The habit of eating earth, 
plaster, and other indigestible and sometimes disgusting substancest 
common among the insane and idiots, and with which pregnan, 
women and hysterical or chlorotic girls are sometimes afflicted is, 



ii 



PICA. 443 

occasionally mot with in chiUhvn who nro not obviously deficient in 
intellect. 

In some instances the habit begins in early infancy, there is no 
impairment of general health, and the practice is abandoned at about 
three years; of age. In other cases the practice begins during ill- 
health at a later age, and disappears when the health im})roves. It 
may thus be met with in children suffering from rickets or tubercu- 
losis, or from intestinal disorders, among which must be included the 
presence of round worms. In such cases the craving for the indi- 
gestible articles may recur more than once at varying intervals. 

The condition must be regarded as a psychosis. When it com- 
mences in infancy, it is as an exaggeration and perpetuation of the 
natural tendency of the infant to carry every object to its mouth. 
A\'hen the stuff eaten by preference is wall-plaster or chalk it has been 
supposed that the habit was an indication tliat the system was in 
want of lime salt, but no simihir explanation can be advanced when 
the material eaten is coal, mud, or sand. 

Infants who indulge in the habit sometimes show great impartiality 
in the objects eaten — plaster, coal, clay pipes, mud, blacking, sand, 
cinders, ashes being taken as opportunity occurs. Cachectic children 
niDre often confine themselves to a single substance.^ 

The children have a dull, heavy look, an earthy complexion, hol- 
low eyes, and an unhappy expression. The only special symptoms 
produced are diarrhcea, which is very usually present, and obstruc- 
tion from im])action of hard masses in the rectum. Dyspepsia is 
often present, and, if not the cause of the habit, tends certainly to 
keep it up owing to the gastric uneasiness wliich it produces. 

The prognosis is good, as has been inferred above, but in a few 
cases a fatal issue has been due indirectly to the malnutrition attend- 
ing the habit of dirt eating. 

The treatment of the affection must be mainly prophylactic. The 
child should be kept out of the way of the indigestible objects which 
it desires to eat, and its mind diverted by suitable amusements. 
Punishment, as in most other morbid habits, is of little avail, but 
judicious moral suasion should be resorted to. Efforts should be 
made to improve the condition of health in general, and of digestion 
in particular. 

•Dr. J«»hn Thomson, Edin. Hasp. Repts., vol. iii., jt. 81. 



CHAPTER XXXIX. 
TETANY AND LOCAL SPASMS. 

Tetany : Etiology ; Symptoms ; Prognosis ; Diagnosis ; Treatment — Local Spasms ; 
Eyes ; Head and Trunk ; Treatment — Habit Spasms. 

Tetany. 

Tetany is a nervous disorder characterized by tonic spasms, affect- 
ing especially the hands and feet (^' carpopedal contractions ^^) and 
due, probably, to chronic intestinal toxaemia. 

The age at which tetany is most frequent is from six months to 
two years ; it is very rare after five years, though it is said to be- 
come rather more frequent about puberty, especially in girls. The 
etiology has been much disputed. The patient belongs, usually, to a 
neurotic family, and has inherited an unstable nervous system, but, 
as a rule, the immediate antecedent of tetany is disorder of the 
digestive functions, though it is observed sometimes as a sequel of 
an acute infectious disease. Occasionally the presence of ascaris 
lumbricoides appears to be the determining cause. It is more com- 
mon in winter and spring than in the warmer season, and an attack 
may be determined by exposure to cold. It has been asserted that 
tetany is merely a symptom of rickets, and Kassowitz has attributed 
the contractures to irritation of the cortical centres produced by the 
hypersemia of bones and meninges associated with cranio-tabes. The 
connection between tetany and rickets, however, is indirect, and is 
to be found iu the gastro-intestinal disorders so common in rickety 
children. The most acceptable theory of the pathology of tetany is 
that under certain conditions of gastro-intestinal derangement, 
among which gastric dilatation is probably the most important, toxic 
substances are produced, which, when absorbed, affect the central 
nervous system. Degenerative changes, probably of inflammatory 
origin, have been found in some cases in the cells of the anterior 
horns of the grey matter of the spinal cord (internal part). 

The onset is preceded by an acute gastro-intestinal attack, or by 
the aggravation of a chronic disturbance already present, and there 
is often some pyrexia. Puffy swelling of the backs of the hands is 
an early symptom. The child cries when moved, the limbs in many 
cases are kept constantly in one attitude, and passive movements 

444 



Ji 



TETAXY. 445 

cause pain. The hands are often clenched. In rare cases the first 
symptom is an attack of general convulsions, or of laryngeal spasm. 

The characteristic symptom is niu.'<cular rigid it i/, seen first, usually 
in the hands. Both the flexors and extensors are aifected, but the 
contraction of the former predominates. The hand may assume 
various attitudes. That most often seen recalls the position of a 
hand holding a pen. The fingers are flexed at the metacarpo- 
phalangeal joints, while the phalangeal joints are extended. The 
thumb is extended and adducted, and the hollow of the palm is 
deep. In other cases the metacarpo-phalangeal and fii-st phalangeal 
joints are semi-flexed, while the last two phalangeal joints and the 
thumb are extended, an attitude which has been compared to that 
of the hand when drying a sheet of paper on a blotting-pad. In 
other cases again flexion is complete, the fingers being clasped over 
the thumb, which is adducted and flexed into the palm. Usually the 
wrists are rigid and flexed, while the elbows are free, but in some 
cases the whole limb is rigid in an attitude midway between prona- 
tion and supination, with the elbow semi- flexed. The attitude is 
shown in the drawing (Fig. 64) from a photograph, and has been 
compared to that of a rider reining-in his horse. The trunk mus- 
cles most often affected are the pectoralis major and the trapezius, 
causing the shoulders to be rigid, or if the trapezius predominate, re- 
tracted. The muscles of the neck may also be affected, the head be- 
ing retracted rigidly. The masseters are contracted in severe cases, 
the jaws being rigidly closed. Xext to the hands the feet are the 
parts most often involved. Usually there is extreme extension of 
the ankle with flexion of the great toe. The muscles of the leg are 
often rigid, but those of the thigh usually escape ; sometimes the 
whole limb is rigid, and rotated outwards (Fig. 64) with the feet in 
the position of valgus. The contractions are nearly always symmet- 
rical, though they are not always equally intense on the two sides. 
The affected muscles are firm to the touch, and both antagonizing 
groups are always contracted simultaneously. 

The excitability of the nerves to the galvanic current and to me- 
chanical stimuli is increased. The latter characteristic condition is 
best observed in the facial. If the finger or the point of a pencil be 
drawn along the skin from the temple towards the chin, there ensues, 
if thi> fnrial irritahHitif be present, a series of contractions in the 
facial muscles on the same side, best seen in the orbicularis palpe- 
brarum. This symptom is generally present, and may be the only 
clear evidence to Ix? elicite<^l. A symptom of the same order is 
TrouMscfw^s sif/ii. If the arm be compressed by an elastic band the 
muscles of the fingers, and sometimes of the fore-arm, ])ass into the 
tetanic condition ; this is attributed to the mechanical irritation of 
the nerve trunks by the ligature, but it should Ix? added that the 



446 



TETANY Ay I) LOCAL SPASMS. 



homologous muscles on the opposite side may also become contracted. 
Kassowitz has asserted that laryngeal spasm is a symptom of tetany, 
and that its occurrence is pathognomonic. This opinion is too ab- 
solute, but it is true that laryngeal spasm occurs with great fre- 
quency in tetany, of which, indeed, it may be the earliest symptom. 
More often the first attack occurs after other symptoms have existed 
for two or three days. The attacks occur at any time of the day or 

Fig. 64. 




Attitude, sometimes compared to that of a rider reining-iu his horse, which may be assumed 
in a well-marked case of tetany. 



night, may be very severe, in some cases become progressively more 
frequent and more severe, and have been known to cause sudden 
death. Arrest of respiration due to spasm of the diaphragm, and of 
other muscles of respiration may also cause death, which may occur, 
too, during an attack of general convulsions. 

Not only does the number of the groups of muscles aifected vary 
in different cases, but in the same case at different times. There are 
periods of more or less complete relaxation. When present the tonic 






TETANY. W 



spasms vary in intensity. When at their height, the temperature 
may be raised 1° or 2° F. The attaeks are attended by pain whieh 
is aggravated by passive movement, or by pressure. G^dema has 
been mentioned as one of the prodromal symptoms ; it is one of the 
most constant throughout the whole course of the disease. It is 
firm and elastic, limited usually to the parts mentioned, but occa- 
sionally widesjiread ; its surface is usually pale, occasionally flushed 
and red. Sometimes irregular areas of erythema are seen on various 
parts of the limbs and trunk. In rare cases, the sheaths of the 
tendons on the dorsum of the hand, and ]iossibly also the metaearjio- 
phalangeal joints, may be found distended. 

The prognosis in children is on the whole good. It depends, in 
large measure, on the character of the gastro-intestinal disorder and 
the general nutrition of the patient. The more widespread and 
severe the contractions, the worse the prognosis. In a feeble infant, 
severe and extensive tetany of the upper and lower extremities, es- 
pecially if accompanied by retraction of the head, is of bad omen. 
Death may be due to exhaustion, or, as already stated, to respiratory 
spasm (laryngeal or diaphragmatic), or to general convulsions. 

The diagnosis is usually not difficult, though the symptoms of 
meningitis may for a time resemble those of tetany. In tetany there 
i- no headache, and even if retraction of the head be present, pain is 
elicited only by movement. The tetanic contractions are symmet- 
rical, the pupils equal, the pulse rapid and regular ; vomiting, if 
present, is not of the cerebral type ; the abdomen is retracted, and 
diarrhrea, instead of constipation, is the rule. 

Treatment, if the theory that tetany is due to intestinal toxaemia 
Ix? accepted, will be directed to the cure of the gastro-intestinal dis- 
order. At first, vomiting should rather be encouraged by giving 
hot water ; but washing out the stomach which has been recom- 
mended, is not free from the risk of causing laryngeal spasm. A 
laxative dose of castor oil or, preferably, calomel should be given 
and repeated ever}- two or three days. A tetany is sometimes due 
to axcarix lumbricoifJe.^, santonin should, in children of over two 
years of age, be given with the calomel. The diet should be reg- 
ulated, and pepsin or papaine should be given. At the same time, 
intestinal antiseptics, such as calomel in small doses (gr. J^), salol, 
l)enzonaphthol, naphthalin, or bismuth carbonate or su))nitrat(' shoidd 
be given in moderate d^jses frequently rej)eatcd. The patient should 
i • protected from cold or excitement, which both tend to produce 
attacks. A general warm bath is the best treatment for the relief of 
the painful spasms. Cold compresses a])plif*d to the hands and feet 
will often relieve the rigidity. A weak galvanic current is also to 
be recommended. The cathode should be j)laced on the back, and 
the anode moved slowly over the affected muscles. During severe 



448 TETANY AND LOCAL SPASMS. 

attacks, threatening life, chloroform must be given by inhalation. 
When the symptoms are severe, but less urgent, chloral should be 
given by enema (gr. iv four times in twenty- four hours for an in- 
fant ; the dose may be doubled if the desired effect be not produced). 
Bromide of potassium, of sodium, and of strontium have also been 
recommended, but do not, as a rule, have much effect. Belladonna 
is more useful, but must be given in full doses. If the child be the 
subject of active rickets, advantage will often be obtained by the 
prescription of phosphorus. The fact that a tetanoid condition fol- 
lows extirpation of the thyroid gland has led to its administration in 
tetany. I have not seen very distinct results from this treatment, 
but Maestro has reported three cases in which recovery took place 
rapidly ; the dose was gradually increased until it reached the large 
quantity of 30 grains of the fresh thyroid daily. 

Local Spasms. 

Eyes. — Nystagmus, which is usually lateral, may be a symptom 
of congenital cataract, or other conditions causing loss or great dimi- 
nution of vision ; of tumors of the cerebellum or pons ; of Fried- 
reich's disease, and disseminated sclerosis ; of tetany ; it occurs 
sometimes in association with convulsions of an epileptiform nature, 
as shown by the subsequent development of idiopathic epilepsy ; 
finally, slight inconstant nystagmus may be observed in infants as- 
sociated in some, but not in all, with error of refraction. The diag- 
nosis of the cause of nystagmus in any case must be made from 
a full consideration of all the attendant symptoms. Constant nys 
tagmus with wide excursion should be suspected to be due to or 
ganic disease. 

Head and Trunk. — Clonic spasm of the muscles of the neck 
causes the head to be rotated, or bent forward, or from side to side. 
Such movements, w^hich are not uncommon in infancy, begin usually 
between the ages of six and twelve months. They are rarely seen 
after three or four years. In rotary spasm, the commonest form, the 
head may be in constant movement, except during sleep, or the move- 
ment occurs at irregular intervals, and resembles exactly the gesture 
of shaking the head in negation. In many cases there is rapid 
nystagmus, which is increased when the head is held, or may then 
only be perceptible. Lateral spasmodic movements of the head, 
compounded of slight rotation and flexion on one shoulder, are not 
very common, and are usually associated wdth nystagmus. A very 
similar, but coarser movement may often be noted in children suf- 
fering from ear disease. In nodding spasm, which is far less common, 
the head is suddenly flexed forward at intervals, as in the gesture of 
affirmation, nystagmus is less common, and, wdien present, has a small 



I 



HABIT SPASMS. 449 

excursion. The prognosis is not good. A large portion of the patients 
do not survive early childhood, and of those wIk^ do many are idiots or 
feeble minded. Spffsiuu^^ nufuns (sometimes called Ju'lmnpsid nuttuw^), 
in which at frequent intervals the head and trunk are bowed forward, 
while at the same time the thighs are slightly flexed, happily called 
" Siilaam spasm" by West, is a serious atfection. In some ciises 
there is a momentary loss of consciousness, and in others, which have 
been followed for a sufficient time, it has been proved to be associated 
with chronic meningitis, or other organic intracranial disease. As 
is the case with all these spasmodic affections, the movement is sud- 
den and jerky, and must be distinguished from the regular slow rock- 
ing to-and-fro of the body on the hips when sitting, which is so 
o^mmon a habit in children with marked rickety deformities, and 
also from the rapid, sideway, jerking movements of the hips associated 
with irritation of the anus or genitalia. Head bdur/inf/ may be dealt 
with in this connection. It is not uncommon in children between 
the ages of six months and three years. It occurs at any time of the 
day, but most often at night ; the child kneels or lies face down- 
wards and bangs its head into the pillow, or the back of the chair. 
It may go on doing this for hours, unless it hurts its head by hitting 
it against a hard ol)ject. If taken into the arms, it will often con- 
tinue to hit its head against the nurse's shoulder. It appears to be 
due in most cases to irritation of the naso-pharynx, ear, or teeth. In 
acute otitis, the child bores its head into the pillow, but does not 
bang it. Other children as they lie on the l)ack constantly rub the 
back of the head into the pillow with a gentle rotatory motion, and 
in time rub the hair over the occiput quite short. In some cases, no 
source of local irritation can be discovered, but both the children who 
bang the head and those who rotate and rub it into the pillow are 
usually rickety, and the movements are possibly due to irritation 
connected with rickety changes in the cranial bones. Spasm of the 
respiratory muscles is referred to on pp. 311-313. 

In the treatment of these conditions search should l)e made for some 
source of irritation with a view to its removal or mitigation. Head- 
banging or pillow-rubbing should suggest the presence of rickets. In 
nystagmus the condition of the ocular media should l)e ascertained. In 
hejul-spasms, associated with lapses of consciousness, the condition 
ihl be regarded as epileptic and should l)e treated accordingly. In 
'l-n^Klding, or rotation without Lapses of consciousness, it appears 
to l)e justifiable to treat the case as one of chronic meningitis, although 
it must be confessed that marked results are hardly to l)e exjiected, 
although in some cases the movements cease eventually. 

Habit spasms, r»r conni/^irc tics, oi' varif»us kinds are common in 
children, and may {KTsist after childhfX)d. In some cases the mani- 
festations are hysterical, or there is at least an hysterical element. 
29 



450 TETANY AND LOCAL SPASMS. 

Others are habits, such as sniffing or clearing the throat, persisting 
after the cause has ceased. Some of the severer forms are associated 
with mental defect, which may amount to idiocy. 

Spasm is most common in the facial area. Sudden contraction of 
the orbiculares palpebrarum is often observed. Occasionally this 
spasm is confined to one side, but is then usually associated with 
spasm of other muscles of the face on the same side, and occasionally 
with spasm of the sterno-mastoid. Or the muscular spasm which 
causes flexure of the head with some rotation is associated with 
spasm of the lower face muscles only, so that the patient looks as if 
he were perpetually settling his collar, and in some cases the trick 
does arise in connection with the wearing of tight bands round the 
neck. In other cases again the facial spasm is associated with con- 
traction of the scalp muscles, causing the hairy scalp to be shifted 
backwards and forwards, or the platysma on one or both sides is 
affected either alone or in association with the facial muscles. The 
movements in habit spasm of all kinds are short and sudden, and 
are usually repeated several times in series at irregular intervals. 
Groups of muscles of the trunk are occasionally affected, causing 
sudden movements ('' electric chorea ''), or the distribution may be 
such that the movement is apparently purposive (e. g., " saltatory 
spasm ^^). In such cases the deep reflexes are usually exaggerated. 

Associated with the muscular spasms, or, in some cases, without 
any very obvious habit spasm, curious mental disturbances may oc- 
casionally be met with. Thus the child may take to uttering sud- 
denly, and without rhyme or reason, interjections such as ^' Ah ! ^' 
or cries of alarm — " Fire ! ^' or " Murder ! ^^ — or oaths and foul ex- 
pressions (so-called coprolalia) ; or may repeat the same word over 
and over again (ecJiolalia) ; or ask the same question with maddening 
iteration (inanie de pourquol) ; or, before performing ordinary actions 
of life, such as putting on its boots, must go through some curious 
antic, or repeat some sentence as though it were an incantation : 
or it must count up to a certain number (arithmomania) ; or, again, 
it has an imperative desire to touch certain objects, so that it cannot 
leave a room without placing a finger on certain pieces of furniture 
(manie de toucher). As to the treatment of these odd tricks, it is 
not easy to lay down any general rules. It is necessary to attempt 
to stimulate the Avill of the patient, and to induce him to exercise 
voluntary control over the movements. The condition is often re- 
lated to hysteria, and educational and other treatment of the kind 
indicated for that condition is of use also for the correction of habit 
spasms. 



CHAPTER XL. 
ECLAMPSIA AND EPILEPSY. 

Infantile Convulsions : Causes ; Symptoms ; Treatment — ?>pilepsy : Etiolofiy ; 
Symptoms ; Jacksonian Epilepsy — Diagnosis of Epilepsy and Eclampsia — 
Prognosis and Treatment of Epilepsy. 

Infantile convulsions {eclampsia). — Convulsions, varying as to 
extent and the parts atlected, are very common in infancy and early 
childhood. 

Convulsions occurring within a few days of birth are usually due 
to injury of the brain at birth. They may be one-sided or general, 
and cease usually after the first fortnight. When observed later 
they will usually be found to have commenced after the age of six 
months. The onset of structural disease of the brain or its mem- 
branes may also be attended by general convulsions ; but, with these 
exceptions, the etiology of infantile convulsions is obscure. The 
development of the nervous system is not complete at birth, and its 
functions are not organized fully until a much later date. The 
lower centres are organized earlier than the higher, and we may sup- 
pose that, wanting effectual inhibitory control from above, they are 
more prone to excessive action in response to peripheral stimuli. 

Rickety children are more liable than others to suffer from con- 
vulsions. The nervous centres share in the defective and perverted 
nutrition, which is the underlying cause of all rickety phenomena, 
while gastro-intestinal disorders, themselves capable of determining 
o^nvulsions, are very common in rickets. In other cases the unstable 
condition of the nervous system is associated with a neurotic family 
history. 

It may be impossible to discover any cause, but in a large pro- 
portion of cases some recognized source of toxemia is present, and 
when it ceases the fits disappear. To this category belong the con- 
vulsions which occur at the (jnset of febrile diseases, or during the 
course of acute or chronic gastro-intestinal affections. In other 
cases, some s^jurce of j)eripheral irritation apj^ears to be the de- 
termining cause, since the fits cease when it is removed. Among 
such sources of irritation must be counted indigestible food, or large 
masses of undigested food in the str)mach, worms or faecal accumu- 
lations in the intestines, disturbed dentition, otitis, and phimosis. 

451 



452 ECLAMPSIA AND EPILEPSY. 

Falls and blows on the head also seem to determine general con- 
vnlsions in some cases. The convulsions which occur as a compli- 
cation of bronchitis, and in rare cases attend the paroxysms of 
whooping-cough, are attributed to cerebral congestion. 

The Jits vary greatly in extent, severity, and duration. If attacks 
of respiratory spasm (see p. 311) be excluded, it may be asserted 
that infantile convulsions are attended by loss of consciousness in 
nearly all cases. Often no premonitory symptoms are noticed, but 
in other cases the child has been restless with twitching of the arms 
and grinding of the jaw. Suddenly the arms and legs become stiif, 
the eyes fixed and staring, or rolled up under the upper lids, respira- 
tion is arrested, the head is retracted, and finally the whole body be- 
comes stiff. This stage of tonic spasm is usually followed by clonic 
convulsions, more or less severe and prolonged, affecting the upper 
and lower extremities, face and eyes. If the tonic stage is brief, 
the clonic convulsions slight and few, the whole fit may last less 
than a minute, and after lying in a drowsy state for a few minutes 
more the child sits up and appears little the worse. In severe cases 
the clonic stage is succeeded by a period of drowsiness or stupor, 
the length of which is in proportion to the severity and duration of 
the seizure. Fits may succeed each other at short intervals, the 
patient may then become comatose, and die in the course of a few 
hours. 

The prognosis depends partly on the severity of the seizures, but 
mainly on the frequency with which they recur. A large proportion 
of the deaths certified as due to convulsions ought more correctly 
to be assigned to the gastro-intestinal, or other diseases of which 
they are complications. On the question of recurrence it is in my 
opinion quite impossible to speak with any confidence, unless the 
convulsions have occurred at the onset of an acute febrile disease, in 
which case a hopeful prognosis is justified. If, after the removal of 
some source of irritation, the fits do not soon recur, the prognosis is 
good. If the fits have already recurred several times, the chance of 
repetition is great, since a kind of habit becomes established. Fi- 
nally, the possibility that the infantile convulsions are the beginning 
of epilepsy must not be ignored. 

The diagnosis will be considered later, under Epilepsy. One- 
sided fits, or those followed by paralysis, are most probably due to 
organic brain disease. 

In commencing treatment attention should be directed to the dis- 
covery of a source of toxaemia or peripheral irritation. If the tem- 
perature be high the probability that the convulsions mark the outset 
of an acute febrile disease should be considered. If indigestible food 
have been swallowed recently, or if the fit have been preceded by 
nausea, the stomach should be emptied by an emetic, or by washing 






EPILEPSY. 45^ 

out. If there be a history of coHe, or recent aeute diarrhcea, ealo- 
mel shoukl be given by the month, and a eopions injection by the 
rectum. If the temperature be high the injection shoukl be about 
85° F. ; if tliere be little or no pyrexia, and in any case if the in- 
fant be feeble, at 07° or 98° F. Subsequent injections may be 
medicated by the addition of antipyrin (gr. iij-iv at one year), which 
is a useful sedative as well as an antipyretic. Chloral is a remedy 
which should be reserved for severe cases. If, however, the con- 
vulsions be long-continued and oft-repeated a little chloroform should 
be given by inhalation, so that time may be gained for other measures. 
A simple warm bath at about 92°-94° F. has a valuable sedative 
effect ; if the body temperature be high, cool affusions to the head 
during the warm bath may be used ; or the temperature of tlie bath 
may be made a little lower. If after the convulsions have ceased 
congestion of the fiice and conjunctiviv persist, a warm pack to the 
legs, or to tlie lower limbs and trunk also, shoukl be given. [A 
mustard-bath mav be given. Mustard-bath — mustard, 1 oz. to each 
gallon of water (at 98° to 106° F).] If the child is much de- 
pressed, brandy or eau de cologne should be added to the water. No 
advantage can be expected from scarification of the gums as a matter 
of routine, but if the mucous membrane be stretched by a tooth near 
the surface, an incision down to the tooth will remove one source of 
peripheral irritation, which is very real, though its frequency and 
importance as a cause of eclampsia has been greatly exaggerated. 
The after-treatment shoukl be systematic. At first bromides should 
be given, or if there be stomatitis or painful colic, opium in small 
doses for a short time. The diet should be regulated, imperfect di- 
gestion or gastro-enteritis combated, rickets treated, and the child 
should be placed under the best available hygienic conditions. If 
convulsions recur, it is advisable, while still giving attention to pos- 
sible sources of irritation at the periphery, to institute a course of 
bromides. 

Epilepsy. — If epilepsy be defined, with Osler,^ as '^an affection 
of the nervous system characterized by attacks of unconsciousness 
with or without convulsions,^' and it w^ould be difficult to frame 
another definition less open to objection, then it follows that no hard 
and fast line can be drawn between infantile eclam})sia and epilepsy. 
Indeed, v. Striimpell - goes so far as to write that " the ('pil('])tic at- 
tacks of infants during the first year are commonly called eclam|)tic," 
and admits only the distinctions that in the iraix^rfectly develo])ed 
brain of the child an epileptic explosion is much more easily induced, 
and that the prognosis is much better. 

'Osier, "Prin. and Prac. of Mecl." Secr>ml ?>liti<.n, 1895, p. 1002. 

^Penzoldt and Stintzing's ** Handlnicli d. Spec Thor.," lid. v., Al)t. viii., j*. 

\. 



\ 



I 



454 ECLAMPSIA AND EPILEPSY. 



Gowers^ found that the ages at which the largest number of cases 
of epilepsy commenced were fourteen, fifteen, and sixteen years, that 
one-fourth of the cases commenced before ten, and one-eighth before 
three. Hasse" states that in 9 per cent, the fits began so soon after 
birth that the epilepsy might be called congenital. The influence of 
heredity is shown by the fact that Gowers^ found that in one-third 
of his cases of all ages there was a history, in ancestors or collaterals, 
of epilepsy or insanity. It is brought out well also by Echeverria's^ 
statistics of 135 families in which either the father or mother was 
epileptic ; there were 554 descendants, of whom 246 died early, 203 
suffered from epilepsy or other nervous disorder, and only 105 were 
healthy. 

The epileptic fit is due to an abnormal discharge in the higher 
(probably cortical) cerebral centres, which affects a larger or smaller 
number. Such discharges may be provoked by organic disease 
(tumour, abscess, etc.) or by trauma. In such cases, which are dis- 
cussed elsewhere, the convulsion may be limited to the correspond- 
ing side of the body. In cases not due to gross organic disease of 
the brain, the determining cause of the fits is not as a rule discover- 
able, and to them, therefore, the term idiopathic epilepsy is commonly 
applied. 

In cases which begin in infancy the conditions already mentioned 
as causes of infantile eclampsia must again be invoked. Peripheral 
irritation seems to be in some cases the exciting causes of epilepsy,^ 
while in a larger number it renders the fits more severe and more 
frequent. Blows and falls on the head which leave no definite evidence 
of organic disease may yet be followed by epilepsy, which is also 
an occasional sequel of exposure to the sun. Toxsemia, from one 
source or another, must be looked upon as the determining cause of 
the initial fits in many cases. It will account for those, not due to 
gross lesion, which arise in the course of acute infectious diseases ; 
scarlet fever, measles, and typhoid fever, especially the first named. 
Again, various conditions of the digestive organs appear to be the 
determining cause in some cases ; thus the fits may date from an at- 
tack of gastro-enteritis. Again, in many epileptic children the 
bowels are constipated, owing apparently to " torpidity ^^ of the liver, 
which is enlarged ; the face has a heavy expression, the lips and 
tongue are congested and there is tenderness, sometimes pain, in the 

'Gowers, ''Dis. of Nerv. Syst," 1888, vol. ii., pp. 676 et seq. 

2Bagiasky, Lehrb. d. Kindrhlde., Vfte. Auf. 1, 1896, S. 539 et seq. 

''In Burchard's case, for instance {Arch, of Ped., 1895, p. 35), a boy began to 
have epileptic convulsions, so diagnosed by, among others, Charcot, at the age of 
ten. When he had reached the age of twelve it was noticed that he had a long ad- 
herent prepuce and discharge from the urethra. Circumcision was performed and 
much retained smegma removed. He had a fit on the first and second days after the 
operation, but not another down to the date, sixteen years after the operation, when 
the report was made. 



EPILEPSY. 455 

hepatic region. Idiopathic epilepsy occurs occasionally as a com- 
plication of inherited syphilis without other discoverable cause. The 
fact that a large number of cases begin at or about the age of puberty 
suggests that the changes in the nervous system whicli attend the 
development of the sexual organs have some influence, and it should 
be noted that during the first three decades of life there is a pre- 
jH>nderance of female cases, es]>ecially marked in the second decade, 
but still noticeable in the third. Masturbation, especially in boys, 
is a frequent concomitant of epilepsy, but whether it should be re- 
garded as a cause or as a common consequence of a remoter cause is 
OjK'U to doubt. Sudden emotions, especially fright, are held to be 
capable of producing cjiilepsy. A lit occurring immediately after 
the emotion is probably hysteroid, but true epileptic tits occasionally 
occur after an interval. Finally, it may be said that there is no 
cause of an epileptic attack so potent as the condition of nervous 
system left by a previous attack, so that, once established, the fits 
may continue long after the exciting cause of the first has been re- 
moved. 

The symptoms of epilepsy in children do not differ from those in 
adults and m'cd not here be descril>cd at length. Children are liable 
both to the grave and to the minor form (petit m<if). It is probable 
that the proportion of cases of petit mat and of those in which the 
fits occur in groups is greater in children than in adults. As 
Henoch has pointed out, it is not uncommon to meet with cases in 
which a child has for years experienced '' j^eculiar sensations " at 
irregular intervals. Finally, the occurrence of an epileptic fit after 
one of these " sensations " shows that they have been aura?. In 
some, at least, of these cases the ^' peculiar sensation " is followed 
by a loss of consciousness, so short that it will nut be noticed unless 
looked for. The seizures of minor epilepsy are often described as 
" faints." The child sinks back in its chair or falls to the ground, 
the face becomes pale, and consciousness is lost. In a moment or 
two it recovers consciousness, but is drowsy. Urine may be passed 
during the fit, and if minor attacks occur at night, occasional noc- 
turnal enuresis may be the first symptom to arouse suspicion, which 
will be confirmed if there be now and then unusual drowsiness in the 
morning and purpuric spots about the neck, or if the tongue l)e found 
bitten. The recognition of the real nature of such cases is impor- 
tant, not only as regards treatment, but also because some patients 
who suffer from nocturnal fits have a tendency to turn over on the 
face and so run the risk of suffocation. Some attacks of minor epi- 
lepsy, especially in girls, are followed by hysteroid convulsions. 
This stiitement would not l)e accepte<l by Charrot and his followers, 
who hold that such fits are from the first hysterical, though they 
admit that the hysterical fits may alternate with the epileptic fits and 



456 ECLAMPSIA ANB EPILEPSY. 



4? 



thus lead to a mistaken diagnosis. In some patients vomiting follows 
the fits, and is a source of danger, as food may be drawn into the 
larynx. Automatic actions immediately after the fits, such as un- 
dressing, climbing upon furniture, or sudden motiveless assaults upon 
others, are observed in some cases in children as in adults. After a 
severe fit there may be temporary muscular weakness amounting to 
actual paresis, hemiplegic or paraplegic in distribution, corresponding 
to the parts most affected during the fit. The mental condition of 
epileptic children varies very greatly. As a rule they are backward, 
but if the fits be neither frequent nor severe there may be little or 
no obvious deterioration, at any rate for some years. If the fits be 
frequent or very severe the child is dull and depressed, and it is 
difficult to teach because the memory is, as a rule, defective. In 
other cases the child, during the interparoxysmal periods, is noisy, 
irritable, and mischievous, subject to outbursts of temper, and shows 
great lack of self-control, and in some cases definite moral perversions. 
In the most severe and progressive cases of epilepsy dementia ensues 
sooner or later. 

Jacksonian, or focal epilepsy, in which the spasms commence in 
a small area, usually one of the limbs, is symptomatic of organic 
irritative disease of the cerebral cortex (tumours, abscess, etc., q. v.). 
The convulsive movements beginning in one limb may be limited to 
it, may extend to the other limb of the same side, or may become 
general. Except in the alternative last named the fits are often, 
perhaps usually, unattended by loss of consciousness. Infantile 
hemiplegia, the onset of which is usually attended by convulsions, 
may be complicated at a later date by epilepsy. If the paralysis 
have almost cleared up it may escape discovery, especially if the fits, 
as happens not infrequently, only recur with severity about the age 
of puberty. 

For the diagnosis of idiopathic epilepsy the point of primary im- 
portance to be recognized is that the fits are recurrent. As has 
already been observed, no hard and fast line can be drawn between 
infantile convulsions and epilepsy, for, as Gowers has said, " when- 
ever attacks continue after their cause has ceased, the condition is 
inseparable from epilepsy.'^ It must be remembered that epilepti- 
form convulsions even in very young children may be ursemic, and 
that convulsions from this cause may be one-sided. The epilepsy due 
to gross lesions will be distinguished by the history, the mode of 
onset of the attacks, their limitation in area, and by the recognition 
of other symptoms of organic disease — headache, vomiting indepen- 
dently of the fits, optic neuritis, paralysis. In epilepsy having its 
origin in infantile hemiplegia careful examination will reveal the 
presence of paresis, rigidity, and exaggerated reflexes on one side. 
Definite hysterical convulsions do not occur in infancy, are very rare 



d 



JACKSOyiAS OR FOCAL EPILEPSY. 457 

in childhood, but become more frequent at ]Miberty. They mav be 
distinguished by noting that they are generally induced by emotion ; 
that the movements, \vhich an* struggling or i)urpt>sive, irregular in 
distribution, and often continued with partial intermissions for as 
long as an hour or longer, are generally accompanied by crying and 
whining ; that the face is flushed ; that the pupils react normally ; 
and that if there be loss of consciousness it does not continue' through- 
out the whole tit. Fits which begin quite suddenly, with pallor of 
the face, fixed pupils, and loss of consciousness, even if these symp- 
toms be followed bv hvsteroid svmiitoms, should be rejrarded as 
epileptic. 

Tiie prognosis of epile}>sy commencing in childhood is worse than 
in adults. Fits which cannot be distinguished from those of epilepsy 
may, when they occur under two years of age, disappear ; but if 
definite recurrent attacks are observed after five or six years of age, 
the prosi>ect of cure is small, tiiough improvement may take place 
under treatment. Immediate danger to life is less than in infantile 
eclampsia, though sudden death is caused occasionally by suffocation 
in bed, or by the impaction in the air passages of food rejected from 
the stomach immediately after the fit. 

In the treatment of epilepsy, it is especially important in you ug 
ciiildren to search for one of the peripheral sources of irritation or of 
toxa^nia mentioned above. Neuralgia, dyspepsia, intestinal worms, 
phimosis, rickets, and anaemia should receive appropriate treatment. 
When constipation is present, saline ajierients are indicated, and their 
use may suffice materially to reduce the number and severity of the 
attacks. If the liver is enlarged, ammonium chloride should be 
given systematically in full doses. In every case, in fact, it is im- 
portant to endeavor to improve the state of the general health, in 
whatever respects it may be found defective, and not to trust alone 
to the routine administration of bromides. Potassium bromide is 
the most efficient of these, and should be given at once in full doses. 
If the fits cease, the drug should not be stop|)ed, though the dose 
may l)e reduced. Premature arrest of a course of bromide is fol- 
lowed, almost invariably, by recurrence, and a,s a rule it is not pru- 
dent to withdraw the drug altogether until the patient has been free 
from fits and " sensation " for several years. The object is to give 
at first as large a dose a ]>ossible, short of producing the symptoms 
of bromide jxjisoning, which are lethargy, physical depression, mus- 
cular weakness, cold extremities, and feeble pulse. Impetigo occur- 
ring as a conser|uence of bromide ingestion shoidd be treated by 
attention to cleanliness, by antisejitic ointments, and by the prescrip- 
tion of small doses of arsenic combined with the bromide. True 
bromide rash, which is, however, rare, may render it necessary to 
suspend the treatment. The drug may be given in three doses after 



458 ECLAMPSIA AND EPILEPSY. 

meals, or, if the fits are usually nocturnal, a double dose, or half the 
daily quantity (at first gr. xxx, increasing to gr. Ix for a child of 
eight), should be taken in the evening. Gowers recommends large 
doses, taken in half a pint of water, at intervals, at first, of two 
days, gradually increased to four days, the doses being correspond- 
ingly increased; both are then decreased, so that the whole course 
lasts six weeks. Subsequently, small daily doses should be given. 
When the drug is given in the ordinary way, the dose may be re- 
duced cautiously when the severity and frequency of the fits have 
distinctly declined. Sodium and ammonium bromides are preferred 
by some, under the impression that they are less depressing than the 
potassium salt. In some cases in which potassium bromide fails to 
produce much effect, the addition of potassium iodide, as recom- 
mended by Brown-Sequard, is followed by rapid improvement. 
Digitalis may be combined with potassium bromide with advantage 
if there be cardiac dilatation and feeble circulation, and Gowers states 
that it is of use also in nocturnal epilepsy. Belladonna, which is 
well borne by children, is useful sometimes, but opium is not to be 
recommended. Borax, which has been strongly recommended as an 
alternative for the bromides when these are not well taken, has never 
in my hands had a favorable effect in children. In cases with a 
prolonged aura, the inhalation of amyl nitrite has been known to 
prevent the threatened attack, and when the aura begins definitely 
in the hand or foot, a ligature round the limb has had the same 
happy effect. It would be useless to enumerate all the drugs which 
have been used with alleged benefit in epilepsy ; our main reliance 
must be upon the bromides coupled with an intelligent treatment of 
any concomitant symptoms. During the fit, little can be done be- 
yond taking means to prevent the patient from injuring himself, 
especially from biting the tongue. Nothing should be given by the 
mouth, and, after the fit, the child should be allowed to sleep. 

An epileptic child should lead a quiet, regular life, free from ex- 
citement. It should be educated either alone, or in a special class 
for backward children, or, and this is probably the best course, it 
should be entered in an epileptic colony. ■ I 

[The surgical treatment of epilepsy has attracted much attention,* ■ 
but, except in a few limited cases, cannot be said to offer much en- 
couragement. It should, of course, be considered only in those 
cases of ^^ partial epilepsy '' pointing to a definite focus of disease. 
Sachs advises that in case of brain injury the damaged tissue should , 
be removed. If allowed to remain he considers such tissue a con- 
stant menace to the patient.] 



11 



I 



CHAPTER XL I. 
MENINGITIS. 

General Etiology and Symptoms : Intracranial Tuborolo ; Tuhereulous Menin^jitis — 

► Anatomy — Etiolotjy — Symptoms — The Diairnosis of ]Monin<ritis — Treatment — 
Posterior Bas;\l Meniniritis — Hydrooephalus. 

Meningitis. — The cdinmonest (v^^^r of acute meningitis in child- 
hood is tuberculous infection, but it may occur in the course of other 
specific infections — small-pox, scarlet fever, measles, enteric fever, 
pneumonia. The symptoms formerly attributed to rheumatic men- 
ingitis are more probal>ly due to hyperjn'rexia. Next to tubercle, 
injury to the bones is the most common cause of acute meningitis in 
childhood. Otitis may lead to meningitis, but more often deter- 
mines inflammation of the substance of the brain or sinus-thrombosis. 
Meningitis may be an incident of general septicjemia, or pyaemia, 
and in some cases the peritoneum, ])leura3, and meninges are affected 
simultaneously with purulent inflammation, the primary seat of 
which cannot be ascertained. 

Acute meningitis may be limited to the base, as is usual in tuber- 
culous meningitis, or to the convexity and superior longitudinal 
sulcus, as is sometimes the case in specific diseases, but when puru- 
lent, it almost invariably quickly becomes general. Cases in which 
the inflammation is limited mainly to the posterior fossa will be con- 
sidered separately. 

Certain symptoms are common to all forms of meningitis. The 
order in which they appear varies, but, as a rule, the earliest is the 
so-called cerel)ral vomiting, in which the contents of the stomach are 
ejected suddenly, without evidence of nausea, and either without re- 
lation to meals or without connection with either undue (piantity or 
improper fpiality of the food. Headache, jiersistent, but sul)ject to 
exacerbations, is often an early symptom and persists after delirium 
has come on. The delirium, which is attended by drowsiness, is, at 
first, a mere wandering at night, with some eager garrulity by day. 
It is generally quiet, though the speech is often hasty and the tone 
anxioiLs. Later it becomes muttering and almost continuous, until 
it is replaced by coma. General convulsions are frequent in infants 
and young chihlren. Paralysis, or more usually paresis of cranial 
nerves, may develop slowly or mpidly, and may disappear and re- 

459 



460 MENINGITIS. 

appear several times. The limbs may be weak, paralyzed, or rigid. 
The convulsions sometimes, and the palsy and rigidity, perhaps, as 
a rule, are hemiplegic in distribution, though complete hemiplegia is 
not common. 

In purulent meningitis the temperature rises quickly, with or 
without rigors, to 103°— 105° F. In other forms it may not ex- 
ceed 100° F., or may even be subnormal until just before death, 
when hyperpyrexia may occur. The pulse may be frequent through- 
out, or after being frequent it may become slow and irregular for a 
time, and then again shortly before death, very rapid. Respiration 
is not, as a rule, quickened in proportion to the pulse. In the last 
stage it may become irregular, with long pauses, or be distinctly of 
the Cheyne-Stokes type. 

Intracranial tuberculosis. — Tuberculous lesions within the cran- 
ium occur under two forms : tuberculous meningitis, which, in its sev- 
eral symptoms, resembles meningitis from other causes ; and solitary 
tubercle, which produces symptoms of the same nature as those 
caused by cerebral tumors generally. 

Tuberculous meningitis is the commonest form of fatal cerebral 
disease in children. The extent of the tuberculous lesions found 
after death varies greatly, and frequently the point of entry of the 
infection cannot be discovered. In some, perhaps the majority of 
cases, the infection of the meninges is a part of general tuberculosis, 
the spleen, the lungs, and the serous membranes generally being in- 
fected ; this is especially the case in the youngest children. In 
others, the meningitis is clearly secondary to some local tuberculous 
infection of the bones, or joints, or of the bronchial, cervical, or 
mediastinal glands. In others, again, the meningitis appears to be 
the primary lesion, tubercle being plentiful in the cerebral and 
spinal meninges, but in other organs absent or scanty. 

Etiology. — F. Brandenburg^ estimated from a study of the cases at 
the Children's Hospital in Basle that tuberculous meningitis consti- 
tuted 8 per cent, of all the cases of tuberculosis occurring in the 
first year of life, 15 per cent, of those occurring in the second year, 
4 per cent, of those in the third, and 37 per cent, of those in the 
fourth year of life. He came to the conclusion that in 34 per cent, 
of the cases of tuberculous meningitis the infection may have been 
derived from some other member of the family. This is about the 
same proportion as for tuberculosis generally. In two-thirds of the 
cases the bronchial glands were found to be caseous, indicating, prob- 
ably, that the infection had found entrance by the air passages. 
Among the determining causes, blows on the head and injuries of 
bones already the seat of tuberculous disease must be reckoned. 
Brandenburg found that in 8.3 per cent, of the cases of tuberculous 
^Jahrb.f. Kinderhlkd., Bd. xxxii., S. 159. 



TUBERCULOUS MENINGITIS. 461 

meningitis the patients had been suifering from tuberculous diseas«!» 
of bone which had not been operated on ; whih^ in IT per cent, it 
followed operations on bone disease. 

Accepting the view that the infective principle is derived from the 
air or food, we may look for predisposing causes to insanitary condi- 
tions, especially overcrowding, with its attendant evils, including im- 
perfect ventilation ; to that hereditary proneness to tuberculous in- 
fection wliich constitutes the tuberculous diathesis ; and possibly to 
intellectual over-strain and worry, though the importance of causes 
of this nature has probably been exaggerated. 

The disease has occurred at the age of six weeks, but it is not 
common in infancy. It is more often seen in the second year of life, 
and is commoner between the ages of two and ten years than at any 
other age. 

Pathological anatomy. — Tuberculous meningitis is essentially a 
basal meningitis, determined by the formation of tubercles in rela- 
tion with the blood-vessels. Frequently ventricular effusion is super- 
added. 

The tubercles, which are usually found in greatest number in the 
fissure of Sylvius, are scattered along the vessels in decreasing num- 
ber from the base upwanls, and may be encountered in the margins 
of the superior longitudinal fissure. They vary in size with their 
age, and at the base the attending fibrinous effusion may be so 
considerable as to mask them. The tuberculous process ap})ears to 
begin in the perivascular space, and to extend along the arterioles 
into the brain substance ; in any case there is always some cerebritis, 
whether secondary to the meningitis produced by the meningeal 
tubercle or set up by the tul)ercle around the vessels penetrating the 
brain substance. In the ventricle, tubercle, if present, is to be 
found in the choroid plexus ; it leads to effusion into the cavity of 
the ventricles with attendant softening of the surrounding cerebral 
substance. To the frequency with which an excess of fluid is 
found in the ventricles, and to the not uncommon existence of very 
copious effusion, the affection owed the term " acute hydrocephalus,'^ 
formerly often applied to it. 

Symptoms. — The nature of the earliest recognizable .symptoms 
varies according as the affection of the meninges is the first, or 
at least the most rapidly developing tubercuhuis lesion, or whether it 
is only a part ; perhaps a late i)art of a general infection. 

In primary tu])erculous meningitis it is customary to describe pro- 
droraatii and three stages of the developed disease, though the symp- 
toms f»f the various stages are far from constant. 

In the profJroinnl fttaf/e certain slight deviations from health ac- 
cfimpany the commencing infection of the meninges. The child 
loses flesh, the bowels are irregular, the appetite is capricious, and 



462 MENINGITIS. 

sleep disturbed. There are momentary attacks of dizziness, or lapses 
of consciousness ; the character changes and the child becomes dull 
and heavy, or alternates between emotional excitement and drowsiness. 

The stage of invasion ensues in a few days, or after a week or two, 
or even longer. The characteristic symptoms of this stage are : (1) 
headache, referred generally to the front or top of the head, and 
persistent, but liable to exacerbations ; (2) vomiting without relation 
to meals ; (3) obstinate constipation ; and (4) irregular, sighing 
respiration, especially if present during sleep. These symptoms in 
a child who has been for some weeks failing in health and altered in 
disposition should lead to a careful examination for other symptoms : 
these are fever (100° to 101° F.) at night, rapid pulse, areas of 
hyperjesthesia, vaso-motor instability, avoidance of noise and light, 
tenderness of the eye-balls, and somnolence. Certain other symp- 
toms may exist from an early stage. Of these, two, if present, are 
extremely characteristic. The one is a striking loss of elasticity of 
the skin, so that a fold pinched up by the finger and thumb only 
slowly disappears ; the other, a peculiar, soft condition of the abdo- 
men, which gives to the hand a feeling precisely like that of a bag 
of dough. Another symptom is slight unsteadiness of the trunk in 
standing (static ataxy). Rigidity of the muscles at the back of the 
neck and retraction of the head are early symptoms when the pos- 
terior fossa is the area affected, or mainly affected. 

The stage of irritation follows usually in about a week, and lasts 
three or four days. It may be attended by a fall of temperature, 
while the pulse becomes slow and intermittent, though easily quick- 
ened by exertion. The respiration also is irregular, and may be dis- 
tinctly of the Cheyne-Stokes type. The headache becomes more 
severe, and may lead to the utterance of a high-pitched cry at irreg- 
ular intervals. Grinding of the teeth and chewing motions of the 
jaws are often present. The child is quietly delirious or somnolent, 
lying on its side with eyes nearly closed, brows contracted, and the 
knees flexed on the abdomen ; the back is also flexed, and when to 
this is added retraction of the head, the appearance is very striking. 
Even in this condition it may be aroused for a moment to answer a 
question, though it resents such interference. The belly remains 
soft, but is retracted (the boat-shaped, or canoe-shaped belly). The 
vaso-motor instability is marked. Stroking the skin with the finger 
is followed by the gradual development of a bright red streak which 
lasts for some time (tdches cerebrales, " cerebral flush ''). During 
this, but sometimes at an earlier stage, affections of the cranial nerves 
may be observed — dilated and unequal pupils, strabismus, partial 
ptosis, imperfect closure of the eyes, slight facial paresis. Optic 
neuritis may exist, and choroidal tubercles may be discoverable. 

The stage of coma sets in gradually ; the temperature rises and 



TUBERCULOUS MEyiXGlTIS. 403 

may attain 104° or 105 '^ F.: the }nilse also becomes more rapid, and 
respiration more irregular. It ooases to be possible to arouse the 
child ; the tongue becomes dry, the lips cracked, the cornea obscured 
by muco-pus. Convulsions, general or partial, may occur, or opis- 
thotonos, and the limbs on one side (seldom one limb only) may be 
paralyzed, while the ocular paralysis grows more marked. Death 
may be determined by exhaustion, hastened by the formation ;)f bed- 
sores, the accumulation of mucus in the chest, or by a convulsion. 

Diagnosis of meningitis. — Certain acute specific diseases, especially 
enteric fever, pneumonia, ear disease, and the general condition pro- 
duced by some intestinal disorders, are liable to be confounded with 
meningitis, and in many instances a confident diagnosis cannot be 
made until after the case has been under observation for some days. 
As a general rule, it may be said that the diagnosis of meningitis 
should not be made until all other conditions which may produce 
similar symptoms have been excluded. This observation applies 
more especially to tubercul(»us meningitis. In acute suppurative 
meningitis, a probable cause is commonly to be discovered, and the 
symptoms are so acute that there is little room or time for hesita- 
tion. The mistake most often made is to attribute symptoms due to 
intestinal disorder to meningitis, and next to that to diagnose tuber- 
culous meningitis when the disease is really enteric fever. In 
doubtful cases the serum test will in future be of great assistance. 
[Lumbar puncture is also of great aid in diagnosis, see p. 126 and 
below.] The resemblance between the earlier symptoms of tuber- 
culous meningitis and enteric fever is, indeed, often very close, and 
it is open to question whether the latter does not in some cases de- 
termine the onset of tuberculosis. In enteric fever, the headache 
may be severe at the onset, and there may be constipation ; while in 
tuberculous meningitis there may be diarrhoea from intestinal ulcera- 
tion, and alxlominal tenderness due to mesenteric disease. Sir Wil- 
liam Jenner has insisted on the diagnostic value of the observation 
that the headache of enteric fever subsides with the onset of delirium, 
while it persists with delirium in meningitis. But this valuable 
criterion may fail us in infants and young children. In infants, the 
conditions corresponding to delirium is characterized by restlessness, 
sudden screams, and an expression of fear. The sudden onset of 
high temperature and headache followed by delirium, or the con- 
dition just described, should suggest in infants pneumonia, and in 
older children either pneumonia or enteric fever. The pyrexia of 
enteric fever is more regular than that of meningitis, while the pulse 
is rapid and does not present the irregularity or slowness so often 
observefl in meningitis. If pneumonia is developing, even though 
no physiail signs can be detected, the pulse-respiration ratio will al- 
most certainly be disturbed, and there will be respiratory movements 



464 MENINGITIS. 

of the nine nasi. The inelastic skin and soft doughy belly of tuber- 
culous meningitis are not observed in any other condition. Oph- 
thalmoscopic examination may reveal choroidal tubercle or optic 
neuritis. The former renders the diagnosis of tuberculous menin- 
gitis certain ; the latter makes it probable, since optic neuritis is rare 
in acute specific diseases, and only occurs in a late stage. The ab- 
sence of changes in the fundus is of no value either way, since cho- 
roidal tubercle is comparatively rarely to be observed during life. 

It is said that ear diseases may produce optic neuritis without the 
intervention of meningitis, and whether this be so or not, it is some- 
times difficult or impossible to decide whether the general symptoms 
which attend acute otitis are due to that condition alone or partly to 
complicating meningitis. All that can be done under such circum- 
stances is to ascertain by paracentesis of the tympanum if pus is 
present in the tympanic cavity, to evacuate it if found, and to watch 
the effect of treatment directed to the relief of the local conditions. 
If the acute otitis involve both ears simultaneously, the resemblance 
is the greater, and the difficulty is practically insuperable. A similar 
difficulty may arise where chronic tuberculous disease of the petrous 
bone induces general symptoms ; unless choroidal tubercles can be 
seen, or tubercle bacilli discovered in the fluid withdrawn by 
Quincke's lumbar puncture, a confident diagnosis of tuberculous 
meningitis may be impossible. 

[There can be no doubt of the diagnostic value of lumbar punc- 
ture in cases of meningitis. Normal spinal fluid is always abso- 
lutely clear ; that from a case of meningitis invariably cloudy. The 
cloudiness may be slight and for detection may require shaking in 
the test-tube and comparison with another test-tube of clear water. 
It is due to the presence of cells, the character of which varies with 
the variety of the meningitis. After withdrawal of the fluid fibrin 
is formed, and Went worth considers these cells and fibrin pathog- 
nomonic of inflammation in the meninges. Albumen is also pres- 
ent in increased amount, from -^q-jq, of one per cent., normal spi- 
nal fluid containing from g^o^-5^-Q of one per cent. 

The following micro-organisms have been demonstrated in spinal 
fluid withdrawn by lumbar puncture from cases of meningitis, either 
by microscopic examination of the sediment, by cultures, or by in- 
oculation experiments : the diplococcus lanceolatus, staphylococcus 
pyogenes aureus, pneumococcus, diplococcus intracellularis menin- 
gitidis^ and bacillus tuberculosis. The last named is often difficult 
to find in cover-glass preparations of the sediment and inoculation 
experiments are sometimes necessary to demonstrate its presence.] 

Infants and young children exhausted by diarrhoea or other de- 
pressing disease may pass into a condition of nervous collapse to 
' Wentworth, loc. cit, p. 127. 



TUBERCULOUS MENINGITIS. 465 

which the terms " spurious hydrocephalus " ami '' hydrocephaloid " 
have been applied. The child is somnolent or comatose, the breath- 
ing shallow, the abdomen soft, and the limbs relaxed. It will be 
noticed, however, that the fontanelle is depressed, the abdomen, 
though lax, is not doughy, there is no elevation of temperature, the 
pulse is regular and often last, and there is no strabisnuis or detinite 
paralysis of the limbs. It must be added, however, that i?i a few 
rare cases strabismus and the general symptoms above noted have 
been known to pass away after the passage of a round worm, and, 
further, that retraction of the head may exist along with the symp- 
toms of spurious hydrocephalus. The diagnosis, in such cases, must 
depend upon careful observation of the case, and of the effects of 
treatment. In older children, lethargy, constipation, and even stra- 
bismus, may be due to hysteria (</. v.) ; but there is no pyrexia, the 
pulse is regular, the strabismus is convergent, and the pupils small. 
Retention of urine or the passage of large quantities of pale urine 
at irree:ular intervals mav be taken to confirm the diao^nosis of 
hysteria ; but, on the whole, the danger is far greater of ascribing 
the early symptoms of tuberculous meningitis to hysteria than of 
falling into the converse error. 

The treatment of acute meningitis, whether suppurative or tu- 
berculous, oifers little hoj>e. The patient should be put to bed in a 
quiet, shaded room, an ice-bag applied to the head, and warmth to 
the feet ; a brisk purge should be given, and a gentle laxative eifect 
kept up by the exhibition of salines. Nourishment must be ad- 
ministered systematically at short intervals, the stomach-tube being 
used if the child refuses food. The value of a mercurial course is 
open to doubt ; it is, of course, out of the question in the most acute 
cases, and not much can be expected from it in tuberculous menin- 
gitis ; at the same time, if the symptoms be less acute, and especially 
if they point to posterior basal meningitis, which is sometimes syph- 
ilitic, it seems to be justifiable to give mercury either by the mouth 
or by inunction as rapidly as jiossible. Even in some tuberculous 
cases slight temporary amelioration ensues. If the outset has been 
acute, and if signs of compression are making their appearance, the 
propriety of draining the excess of fluid from the cranium should be 
considered l)efore coma has iK'Come estai)lishe<l. Quincke recom- 
mends that puncture should be made in the lumbar region, this part 
being chosen because the spinal cord ends at the lower border of the 
first lumbar vertebra. The patient is placed in the sitting posture, 
and l)ending forward ; the needle of a sterilized syringe is pushed 
into the canal in an u])ward direction l>ctween tlic second and third 
or third and fourth lumbar vertebne ; as nuich as ^ iij of fluid may 
bf» drawn off slowly. If the case be tuberculous, the tubercle bacil- 
Im- may be found in this fluid. A large (juantity of albumen in the 
3o' 



466 3IENmGITIS. 

fluid rather points to the meningitis not being tuberculous. At this 
stage of the case it will be desirable to consider whether it may not 
be possible to attempt continuous drainage of the cranium by trephin- 
ing, and putting a drain, if necessary, even into the lateral ventricle. 
It seems clear that this treatment has prolonged life even in tuber- 
culous meningitis, and it is possible that recovery may thus be 
brought about, as in tuberculous peritonitis. [' ' Freyhan found the 
tubercle bacilli in the cerebro-spinal fluid of a patient who recovered ^' 
— Sachs.] 

The prophylaxis of tuberculous meningitis deserves special atten- 
tion. In a child with tuberculous tendency, whether hereditary or 
acquired, any sign of over-pressure at school should lead to im- 
mediate relaxation of studies ; the liability to tuberculous meningitis 
diminishes after puberty, and such children are usually quick and 
studious, so that they rapidly make up leeway. Attention also 
should be given to the diet. The appetite is capricious ; it will often 
be found that the amount of food eaten, in particular the quantity of 
fat is very small. Cod-liver oil is to be recommended, and will 
sometimes be well borne, even in large doses, when ordinary fatty 
foods excite only disgust. 

Posterior basal meningitis not due to tubercle is met with most 
often under the age of twelve months, but it is not unknown after 
that age. It presents a characteristic train of symptoms. Of these, 
cervical opisthotonos is the most constant, and usually the earliest. 
The retraction of the head may develop slowly or rapidly, and is 
accompanied at first by vomiting and irritability, later by stupor. 
Convulsions may occur at an early stage, but tonic spasm is through- 
out the dominant symptom. The rigidity may affect not only the 
muscles of the neck, but also those of the back generally, of the 
lower limbs, which are rigid in extension, and of the upper, which 
are rigid in flexion (Figs. 65 and 66). The stupor is associated 
usually w^ith accumulation of fluid in the ventricles, evidenced by 
bulging of the anterior fontanelle. Squint is not uncommon, and 
nystagmus occurs in some cases ; but optic neuritis is rare, though 
some diminution of vision, if not complete loss of sight, appears to 
be the rule. Slowing of the pulse is much less common than in 
tuberculous meningitis, but may occur, especially in children over 
one year of age. The respiratory rhythm is frequently disturbed. 
Cheyne-Stokes rhythm may occur, but a modification in which the 
pause is followed by one or two deep inspirations is more usually 
observed. The abdomen is not retracted, and constipation is not the 
rule. There may be no fever during the whole time the child is 
under observation ; but if the case is seen from the earliest stage, 
some elevation of temperature will usually be found to occur then, 
and in many cases to recur at irregular intervals. Death is some- 



I 



POSTEBIOB BASAL MEyiXGlTIS. 



4(\' 



times preceded by hyperpyrexia. Tlio course of this iorni ol* menin- 
gitis IS usually long—seldom loss than a month, olten two or throe 



Fk;. 05. 




months. The younger the patient the more acute the course. Some 
patients recover, though what proportion it is not possible to say ; 
the retraction of the head passes away, and vision and intelligence 

Fig. 66. 











Posterior basal nienin^tL<», showiDg the characteristic attitude. From photographu (l.y Dr. 
Dtdlet W. Collixos) of a child under the care of Dr. Church in St. Bartholomew's Hospitali 
rhe patient erentually recovered sufficiently to leave the hospiul. 



468 MENINGITIS. 

are regained ; but some enlargement of the head, doubtless due to 
hydrocephalus, remains and may be conspicuous for some years. 

The morbid anatomy of the condition is so far simple that there 
is in all cases meningitis which begins at the base, and is always 
most marked in that region. It may remain limited to it, or may 
extend to the temporo-sphenoidal lobe, or even to the vertex, or 
downwards into the vertebral canal. It is plastic, and adhesions are 
very prone to occur both at the base of the brain and in the spinal 
canal. Hydrocephalus, which is so commonly produced, is due, in 
most if not in all cases, to adhesions contracted between the cerebel- 
lum and medulla, closing the foramen of Magendie or that of Monro, 
or the aqueduct of Sylvius, obliterating the fourth ventricle, or 
blocking the posterior arachnoid cistern, or the spinal canal in the 
cervical region. The fluid by which the ventricles are distended 
may be turbid and contain fibrinous flakes, but probably only when 
the inflammatory process is still active. Later it is clear, and con- 
sists of pure, or almost pure, cerebro-spinal fluid. 

The etiology is obscure ; traumatism may account for a small pro- 
portion of cases ; probably, in the majority, the meningitis is 
secondary to a catarrhal process involving the middle ear. The ex- 
tension of the infection is no doubt due to micro-organisms. Prob- 
ably more than one variety is capable of causing limited meningitis 
in this region, but the varieties have not been identified. 

The prognosis in any case in which the diagnosis can be made 
with confidence is bad. Death is the rule, recovery the exception. 
The more rapid the onset, the greater the probability of a fatal issue 
at an early date. In such cases the respiration may become sud- 
denly shallow and slow, or irregular. Cyanosis ensues, and the 
child dies. When recovery does occur it is in many cases complete — 
the rigidity passes away entirely, vision is regained, and the de- 
velopment of the brain does not seem to be permanently retarded, 
though the head may remain obviously enlarged, owing probably to 
persistent ventricular eflusion. In other cases chronic progressive 
hydrocephalus {q. v,) ensues. 

The diagnosis in a well-marked case with constant retraction of the 
head, irritability passing into stupor and coma, and alteration of the 
respiratory rhythm is comparatively easy, the only difficulty being 
to exclude tuberculous meningitis. In the latter, though tonic spasm 
may occur, clonic spasm, due to involvement of the cerebral cortex, 
is often a prominent symptom, and there is marked retraction and 
doughiness of the abdomen. The course is, moreover, generally 
more acute, and the symptoms more variable. Further, tuberculous 
meningitis is not very common during the first year of life. On the 
other hand, there may be considerable difficulty in diagnosis in the 
early stage. Retraction of the head may be due to tetany, or to 






CHBOSIC HYDROCEPHALUS. 4G9 

peripheral irritation (seo pp. 34, 445). In tetany, however, the tonie 
spasm is not constant in degree, tlie hands and feet are nsnally 
affected at an early date, and other signs of tetany may be eheited. 
With regard to middle-ear disease, the question is somewhat different. 
It is certain that a certain number of cases presenting symptoms 
suggesting posterior basal meningitis recover after treatment directed 
to the ear, and if it be accepted that this form of meningitis is usually 
secondary to otitis media, it may be held that the treatment of the 
ear disease has cut short a commencing meningitis. If this be ad- 
mitted!, then it Avould follow that a very considerable ]>roportion of 
the cases of posterior basal meningitis recover. In all probability, 
however, otitis media is itself capable of producing more or less 
marked retraction of the head. 

The point is of the less importance to decide because it is desirable 
to assume that all cases presenting symptoms of ear disease call for 
immediate treatment, whether avc hokl that the cure of the ear dis- 
ease has the effect of preventing or of curing the meningitis. Even 
in the absence of distinct indications of pain in the ear it is, there- 
fore, justifiable to incise the tympanic membrane, since the operation 
is in itself harmless. If no pus be obtained, and the wound lual 
rapidly, it will be well to repeat the incision should the symptoms 
persist. When first seen the patient should be put upon small doses 
of calomel (gr. ,V ^^ iV ^^^^^' times a day), whicli has the double ad- 
vantage of controlling the diarrhcea so often present, and of j)roduc- 
ing a mild degree of mercurialization. Small doses of bromide ^vill 
often prfKluce much relief, and diminish the irritability and tendency 
to vomit — an important point, since many cases succumb to exhaus- 
tion when the disease appears to be subsiding. When the symptoms 
persist, and especially if the anterior fontanelle l)e tense, the advis- 
ability of an operation to drain away the fluid must be considered. 
Lumbar puncture is not appropriate, because the effusion is limited 
by adhesions which are prol)al)ly not lo^ver than the U])per cervical 
region. The region of the fourtli ventricle and the posterior arach- 
noid space can l)e reached by trephining the occipital bone close to 
the foramen magnum.' 

Chronic hydrocephalus is the term applied to conditions in which 
there i- an undue a(einmihitif>n of Huid within the cranium, either in 
the ventricles (internal hydrocephalus) or between the dura mater 
and the arachnoid (external hydrocepiialus). It is extended some- 
times to include the redematous condition j>roduce(l by Bright's dis- 
ease or anjcmia. 

Chronic external hydrocephalus is an extremely rare cr)ndition. It 

The reader desiring further information r^hould consult the discussion u|»on IM*. 
W. Carr'f* paper read l»efore the Rf»val Medical and ('h\rur^\ri\\ Socictv (I'ror. R. 
M'fl. Chi. Soc., April Vi and 27, 1897). 



470 MENINGITIS. 

is due to a chronic membranous inflammation of the dura mater and 
araclinoid, with oifusion into the sub-dural space. It is complicated 
frequently by haemorrhage into the false membrane. The effusion 
may be general, so that the brain lies at the bottom of the cavity. 
On the other hand, it may be limited by adhesion, so that in reality 
the condition is one of cyst. 

Chronic internal hydrocephalus is the common form of ^^ water on 
the brain. '^ The effusion may be so great that the bones of the skull 
are forced apart and thinned, Avhile the brain itself is a mere sack of 
nervous tissue enclosing the fluid. The distension may occur dur- 
ing intra-uterine life, the enlarged head may be the cause of difficult 
labor, and the child may die during parturition. Or the enlarge- 
ment may first become noticeable from three to six months after 
birth, or in rare cases later. 

The fluid in the ventricles has the normal chemical characteristics 
of cerebro-spinal fluid, and not those of dropsical effusion.^ The 
accumulation, therefore, must be due either to an excessive secretion 
or diminished removal of the normal cerebro-spinal fluid. This 
fluid is present normally in the cerebro-spinal cavity (cerebral ven- 
tricles and central canal of the cord) and in the sub-arachnoid and 
sub-dural cavities. The fluid within and without the cerebro-spinal 
cavity is in communication through the foramen of Magendie, the 
aperture in the fold of pia mater which forms part of the roof of the 
fourth ventricle. This aperture may easily become obstructed by 
meningitis in the neighborhood. The obstruction may be in the 
iter, or at the foramen of Monro, in which case the dilatation is 
limited to the lateral ventricles. The choroid plexus may be found 
thickened and sclerosed, or the ependyma of the ventricles thickened 
and granular as though from antecedent inflammation. It is prob- 
able that in some cases the process is syphilitic. In acquired hydro- 
cephalus the conditions may be similar, but the distension seldom 
attains the same degree. Among the causes must be mentioned pos- 
terior basal meningitis [q. v.), and tumours so situated as to obstruct 
the return of venous blood from the ventricles. 

The quantity of fluid, especially in congenital hydrocephalus, may 
be very large, causing immense distension of ventricles, flattening 
and spreading out of the convolutions, and a distortion of the cranial 
outline, due in part to its great size, and in part to the separation of 
the cranial bones at the sutures, the frontal bone being tilted forward, 
the parietal bones outward, and the occipital backward. The general 
form of the cranium is globular when the enlargement begins in the 

' Halliburton, ''Chem. Phys.^ and Path." London: 1891, p. 358. The 
cerebro-spinal fluid should be classified with secretions rather than with transuda- 
tions. **It is normally present in sufficient quantity to exercise a considerable 
amount of pressure." 



i 



CHROXIC HYDROCEPHALUS. 



471 



first few mouths of life. When it begins after six months the in- 
crease in breadth is more markeii, and the head has a j^ear shape, 
flattened above, where the anterior fontanelle, greatly enh\rged, forms 
a large flat or slightly bulging area. In any case, the fiice, which is 
often emaciated, appears very diminutive in contrast with the dis- 
tended skull (^Fig. (38). The scalp is thin, and the hair of the 
head scanty. Owing to flattening of the orbital plates of the frontal 
bone the eyeballs are dei>ressed, and the sclerotic is visible below 



Fig. 6" 



Fig. 08. 





Fig. 67, " Mongolian" Idiot. To be contrasted with cretins Figs. V) and 24 ( Dr. Telford-Sraith's 
case). Fig. 68, Hydrf»cephalus, chronic stage. The head was so lieavy that it had to bo propped 
against the back of the seat : the child having looked up with the head a little bent forward, the 
sclerotic is not well seen above the cornea. 



the upper lid, while the iris may be partially covered by the lower. 
Congenital hydrocephalus occurs often in infants who present also 
spina bifida, cleft palate, or other faults of development. 

Course. — Infants who suffer from congenital hydrocephalus, in 
whom enlargement of the head is present at birth or becomes con- 
spicuous soon after, are weakly and ill nourished. They arc dull, 
torpid, drowsy. They may suffer from convulsions, or from febrile 
attacks, after which they are .somnolent or comatcse. They seldom 



472 3IENINGITIS. 

survive many months, death being due to progressive exhaustion, or 
to an intercurrent disease (e. g., broncho-pneumonia). If the en- 
largement begin after three or four months of age, it may be pre- 
ceded by symptoms of meningitis, by convulsions, or merely by 
drowsiness and torpidity. The anterior fontanelle becomes tense and 
enlarges, the sutures separate, and the head assumes the shape already 
described. In the majority of cases the symptoms are progressive, 
and death ensues in a few weeks or months ; in others there are dis- 
tinct remissions ; in a few complete arrest. Should this occur, ossi- 
fication of the cranium proceeds, and Wormian bones often form, 
the skull is thin and long, remains pliable, especially at the anterior 
fontanelle. 

Nervous symptoms due to chronic hydrocephalus are not definite. 
The child is dull in intellect, often idiotic. There may be diver- 
gent squint, and in severe cases blindness due to optic nerve atrophy. 
The limbs are weak, the lower often contracted. The prognosis is 
bad, since it is rare for infants who have once presented marked dis- 
tension to survive beyond two or three years. If they do, they are 
stunted in mind and body as a rule, though in slight cases, in which 
arrest occurs early, intellectual development may not be very con- 
spicuously incomplete. The diagnosis is easy once distension has 
been produced, although the mistake of attributing rickety enlarge- 
ment of the head to hydrocephalus is sometimes made. The form of 
the head, the condition of the bones, and the concomitant symptoms 
ought to prevent such an error if ordinary care be taken. 

The conditions upon which chronic hydrocephalus depends afford 
little scope for treatment. If a case of acquired hydrocephalus be 
seen in the early stage while enlargement is moderate but progres- 
sive, a mercurial course followed by potassium iodide should be tried. 
AVhether the hypothesis that some of the more chronic cases are due 
to syphilis be correct or not, it is certain that a remission and, in a 
few cases, a complete arrest occurs under the use of mercury and 
iodide. This is the only treatment to which I have ever been able 
to attribute the least effect. The application of iodoform ointment 
to the scalp is useless, and so also is strapping the skull. The with- 
drawal of fluid from the ventricles by puncture made at the vertex 
a little to the right or left of the middle line, so as to avoid the longi- 
tudinal sinus, is, with antiseptic precautions, a justifiable operation, 
but as a rale the fluid accumulates again with great rapidity. Punc- 
ture followed by the injection of solutions of iodine or perchloride of 
mercury has not been followed by improvement. Diuretics and 
purgatives produce little or no permanent effect, although a single 
dose of calomel at the onset of one of the exacerbations will some- 
times give considerable relief. 



CHAPTER XLII. 



of the Brain : Course : Diagnosis ; Treatment — Thrombosis of Cerebral 
Sinuses — Intracranial tumour. 



I INTRACRANIAL ABSCESS, THROMBOSIS, AND 
I TUMOUR. 

Abscess of the brain. — Suppuration of the brain is, as a rule, 
eontined to the white substance. It is very rare under one year and 
not common under ten years of age.^ Abscess of the brain may be 
secondary to disease or injury of the cranial bones (inchiding ear 
disease), or may be associated with suppuration elsewhere. In the 
latter case it is generally multi})le, in the former frequently, the 
process being either a part of a general pviemia or of pytemic nature. 
By far tlie most common cause of brain abscess, especially in chil- 
dren, is disease of the ear. According to Korner's statistics, in 77 
cases of brain abscess at all ages 25 were secondary to ear disease. 
The otitis may be recent and acute, or there may have been otorrhoea 
for many years. Among the rarer causes mention may be made of 
disease of the nose. 

Al)scess from ear dkeane in the large majority of cases is single, 
and is situated on the same side as the diseased ear, either in the 
tempo ro-sphenoidal lobe, or more rarely in one of the lol^es of the 
cerebellum. In most cases — .3>^ out of 40 (Korner) — the bone itself 
is diseased. Abscess of the brain, as well as in meningitis and 
8inus-thromlx>sis, secondary to otitis, l>egin, as a rule, at a point cor- 
responding to that at which the inner surface of the bone is attacked. 
The roof of the tympanum enters into the middle fossa, and the 
bfjny partition is sometimes as thin as writing-paper ; it is for this 
reason that disease of the middle ear most often causes abscess in the 
teraporo-sphenoidal lobe which lies on the fossa. The mastoid cells 
are separated from the posterior fossa by a thin layer of bone, and 
hence abscess, secondary to disease in that region, is often situated 
in the cerelK-llum. The extension of the disease to the brain is due 
to thrombosis extending from the diseased bone, or from the ear, 
through the veins which pierce the roof of the tympanum ; only 
rarely is there a direct communication by a suppurating tract. In 

Thit of 223 ca>«es Gowers found 24 from one to nine years, an<l 48 from Un lo 
nineteen. 

473 



474 lyTBACBAyiAL ABSCESS, THROMBOSIS, AND TUMOUR. 

common Avith other forms of intracranial inflammation due to ear 
disease, abscess occurs more often on the right than on the left side. 

The course of abscess may be acute or chronic, or rather intermit- 
tent. The mode of onset varies. There may be well-marked initial 
symptoms, resembling those of meningitis, which indeed is often 
present. The most prominent are headache and vomiting accom- 
panied by pyrexia, which may be attended by rigors or general con- 
vulsions. This condition may run on into the terminal stage, or it 
may be succeeded by a period of latency. On the other hand, the 
earlier symptoms may all be those of this latent stage. They are 
headache, more or less constant and severe, accompanied by occa- 
sional nausea or vomiting. The attacks of headache may alternate 
with otorrhoea, the pain in the head coming on when the discharge 
stops. Convulsions, which may be one-sided or general, resembling 
idiopathic epilepsy and liable to be mistaken for it, are in some in- 
stances the first indications of cerebral disturbance. This stage may 
terminate snddenly by rupture of the abscess, usually into the men- 
inges, producing acute general meningitis. The terminal stage is 
characterized by convulsions, pyrexia, and delirium followed by stu- 
por. The onset of this stage in abscess due to ear disease is often 
determined by exposure to cold, by a blow on the head, or by the 
entry of water into the ear during bathing. Discharge from the 
ear is arrested, and unless a history can be obtained, the previous 
existence of ear disease may pass unsuspected. 

The severity of the headache attending abscess varies ; in abscess 
from ear disease it is often referred to the ear. It is intermittent 
or subject to exacerbations, as is shown in the young child by sudden 
fits of screaming, during which the child covers the ear with the 
hand or tears at it. Vomiting and giddiness are most prominent in 
cerebellar abscess, but may be present in cerebral suppuration. 
Grinding of the teeth and chewing motions of the jaws are often ob- 
served. Convulsions are as a rule general, but the onset of hemi- 
plegia may be preceded by a one-sided convulsion. In some cases 
paralysis is replaced by well-marked rigidity affecting generally both 
lower limbs. Optic neuritis is observed more often in cerebral than 
in cerebellar abscess. The headache may be accompanied by 
photophobia, but ocular paralyses are on the whole rare, though 
ptosis is not very uncommon. In ear disease paralysis of the facial 
may be produced by the bone disease, but with these exceptions the 
cranial nerves usually escape. During the quiescent stage there is i 
often mental depression, which may persist in the acute stage, pass-.j 
ing into stupor and coma with little or no intervening delirium. ■ 
The acute phases are accompanied by pyrexia, by sweating, and often ' 
by rigors, but in the quiescent stage there may be no elevation of 
temperature. Anorexia is a prominent symptom even in the latent j 



ABSCESS OF THE BRA IX. 475 

stage, and constipation is common. In the ntnitc staiic all nourish- 
ment is refused or taken with ditlieulty, the tonoue is drv and hrown 
and constipation obstinate. Both pulse and respiration are (piiekened 
in association with pyrexia, and may be irreonlar ; towards the end 
the pulse may become very slow, and this may be so even when 
other symptoms are not well marked. Owino: to the freipiency with 
which cerebral abscess occurs in the temporo-sphenoidal lobe, localiz- 
ing symptoms are commonly absent, but if the su})puration be im- 
mediately beneath the motor areas — an event most likely to occur in 
traumatic abscess — unilateral convulsions and ]iaralysis may be pro- 
duced. The abscess may rupture into the ventricles, ])r<)ducing 
general convulsions and coma, quickly followed by (l(>ath. In cere- 
bellar abscess the headache is occipital or is described as darting 
backward from the ear. Well-marked retraction of the head, due to 
meningitis of the posterior fossa, may be present and the abscess 
may rupture into this fossa, producing general convulsions followed 
by the symptoms of acute basal meningitis. The prognosis is ex- 
tremely grave once the acute or terminal symptoms of abscess begin 
T.t develop. Unless relieved by surgical means, they terminate in 
death as a rule in f nir or five days or less, though life may be pro- 
longed for a week or more. 

The diagnosis of abscess within the cranium is often difficult ow- 
iug to the resemblance of the symptoms, if acute, to meningitis, or 
if chronic, to tumor. A long history of intracranial symptoms, and 
es})ecially the presence of cranial nerve paralysis and well-marked 
optic neuritis, is in favor of tumour, as is also retrogression of the 
symptoms. Even if evidence of meningitis exist, it must be re- 
membered that it may be secondary to tumour. Pyrexia, especially 
if remittent, would point to abscess, but the main ])oint in the diag- 
nosis of this condition must be the recognition of some condition 
likely to determine it. The diagnosis from otitis is difficult, but 
pronounced cerebral symptoms and optic neuritis complicating ear 
disease, especially if accompanied by cessation of discharge, would 
justify a diagnosis of abscess (see " Sinus Thrombosis "). In young 
children ear disease may be suspected if, in the absence of evidence 
of local disease elsewhere, there Ix? persistent heaviness, restlessness, 
constant whining and attacks of screaming, during which the head 
i.s bore<l into the pillow or rubbed against the nurse's arm, or if the 
child during the screaming carries the hand to the side of the head 
and tears at the ear. 

The serious ])rognosis of cerebral abscess renders its prophylaxis 
a matter of great importance. The ]>ossibility of its developnient 
should be present to the mind in dealing with all cases of ear disease 
in childhood. It is most imi)ortant to treat otorrhrjea systematically, 
and to warn parents of the dangers of blows on the side of the head, 



476 INTRACRANIAL ABSCESS, THROiMBOSIS, AND TUMOUR. 

of exposure to cold, and of sea bathing, unless special care be taken 
to prevent the entrance of water into the ear. At the same time, 
every available means for the improvement of the general health 
should be taken, including the use of tonics and cod-liver oil. Resi- 
dence in a dry, bracing climate is also to be recommended. The 
treatment of abscess so soon as a diagnosis can be made with reason- 
able probability is a surgical question. When there is reason to 
fear that abscess is developing, the child should be kept at rest in a 
cool, shaded room, an ice-cap applied to the head and warmth to the 
feet. It will generally be desirable to give a brisk purge (calomel 
and jalapine), and the diet should be very light. The value of 
morphia may be doubted ; it may possibly exercise a beneficial action 
on the progress of the inflammation, but by relieving the pain it may 
mask the symptoms and thus lead to the loss of valuable time. 

Thrombosis of cerebral sinuses. — Thrombosis of a cerebral 
sinus in children may be primary, that is, due to a general maras- 
mus, or may be secondary to a local disease, or injury of the bone or 
ear. 

Marasmic thrombosis is very rare, or, at least, rarely diagnosed. 
The subjects are infants or children who have been brought to a con- 
dition of collapse by diarrhoea. For practical purposes, it may be 
regarded as occurring only in the superior longitudinal sinus. The 
symptoms are somnolence, apathy, vomiting and general convulsions. 
Cerebral anaemia (see ^' Spurious Hydrocephalus^'), which is also 
brought about by diarrhoea in marasmic children, produces similar 
symptoms, so that the diagnosis of thrombosis can be made only 
when other special symptoms due to the impediment to the circula- 
tion are superadded. These are oedema of the scalp, of the side of 
the head, and of the forehead, epistaxis, and prominence of the fon- 
tanelle which has previously been collapsed. When the clot extends 
into the internal jugular, the external jugular will be over-full, and 
the thrombosed vein may be felt as a hard band. 

Secondary thrombosis, in most cases, affects the lateral sinus, and 
is due to suppurative otitis media. 

Korner^ found the relative frequency of the forms of fatal inter- 
cranial inflammation to be as follows : sinus-thrombosis and pysemia, 
41 cases; abscess of brain, 43 cases; meningitis, 31 cases. Two or 
more of these conditions might be present together, so that there 
were altogether among the 115 cases, 50 examples of abscess and 53 
of sinus disease. Korner states that more than half the cases of 
sinus disease (82 out of 151) occur in the first two decades, but the 
complication is much more common between ten and twenty (56 cases) 
than under ten (26 cases). 

The thrombosis may be brought about by direct extension from 
^ Die otitisch. Erkrank. des Hirns, etc., 1896. 



INTRACRAyiAL TUMOUn. 477 

the inflamed bono, or by extension by aecretion of a septic elot from 
the veins of the mastoid eells. which open into the h\tcral sinns. The 
ck^t may break down and pnuhice secomUiry pyaMnic abscesses, espe- 
cially in the kings. The symptoms' are the sudden onset in a person 
who has suffered for a year or nun'e from ]nnMdent (hscharoc from the 
ear, of fever accompanied by headache, vomitino-, and ])ain in the af- 
fected ear, the discharge from Avhicli has ceased, as a nde. The fever 
is at first high, lOo^-lOo'' F.; the temperature soon falls to 100° F., 
or lower, but its course is very irregular. There is local tenderness 
and (cdema over the mastoid process, and below the external (Occipital 
protubemncc, and stiffness of the muscles of the back or side of the 
neck ; in some cases optic neuritis develops eventually. Tlie patient 
becomes apathetic, somnolent, or delirious, and, finally, C(^matose. 
All these symptoms are seldom present together, and it is justifiable to 
make the diagnosis,- if in the course of chronic suppurative ear catarrh 
there is a sudden cessation of catarrh accompanied by persistent ])ain 
in and around the ear, a high temperature, with marked fluctuations 
and frequent rigr^rs, vomiting, rapid pulse, and constant headache. 
The occurrence of optic neuritis would clinch the diagnosis, but, in 
the presence of severe general symptoms, it will not be prudent to 
wait for its development before advising operation. 

The prognosis is grave, though occasionally a sudden attack with 
headache, earache, vomiting, drowsiness, and fever may clear off after 
the s{X)ntaneous occnrrence of a free purulent discharge from the ear. 

The only effectual treatment is to give exit to the pus by operation, 
and it is essential that this should not be too long deferred. 

Thromlx)sis may be secondary also to suppuration in the nose or 
eye, of the skull and scalp, or to erysipelas ; thus, thrombosis of the 
cavernous sinu.^, a rare occurrence, may be due to extension from the 
ophthalmic veins (in phlegmonous inflammation within the orbit) or 
from the lateral or petrosal sinuses. The special symptoms it pro- 
duces are a pushing forward of the eye, ptosis and paralysis of the 
sixth and other ocular nerves, and adema of the lids and of the root 
of the nose. 

rhromlx)sis of the veins of Galen^ leading to effusion int<> the 
vfiitriclos. has nccnrrrd as a fatal complication of scarlet fever. 

Intracranial tumour is, relatively to the number living at the 
ages, rarer in childhood than in middle life. The actual number of 
cases of intracranial tumour iu children is, however, large. Over 18 
per cent, of the cases at all ages occur in the first decade of life, and 
14 per cent, in the second.^ The large number of cases in childlKK>d 
i.s due, in the main, to the relatively great frequency of tuberculous 

• Ballance, Lnnwt, vol. i., p. 1114, 1890. 
'MilliKan, LnnM, vol. i., p. 981, 1895. 
•Gowers' " Manual of Dif*ea.«*es of the Nen'oua Sy»teni," v<»l. ii., p. 454, 1888. 



478 INTRACRANIAL ABSCESS, THROMBOSIS, AND TUMOUR. 

tumours. Au analysis of Bernhardt's^ statistics shows that of 59 cases 
under ten years of age, in which the nature of the tumour was stated, 
it was tuberculous in 37 (63 per cent.). In the second decade, of 45 
cases, 13 were tuberculous. Next in frequency, are gliomata and sar- 
comata, then cystic parasites (hydatids and cysticercus). Gummatous 
tumours have been met with in childhood, but are very rare, as are 
also dermoid cysts and carcinoma. 

Tuberculous tumours vary in size from that of a filbert to a walnut, 
or even larger. They occur most often in the substance of the brain, 
but occasionally spring from the membranes or from the surface of 
the brain. They are cheesy in the centre, but are surrounded by a 
grey zone of proliferation where the tuberculous process is spreading. 
In children under ten, several tuberculous tumours are found rather 
more often than a solitary tumour. The most usual site is in relation 
with the cerebellum ; for the rest, they occur with about equal fre- 
quency in relation with the cerebral hemispheres, the basal ganglia, 
and the pons. In most cases, tubercle is found elsewhere in the 
body, and some cases terminate by tuberculous meningitis. 

Gliomata are infiltrating growths ; thus in the pons they may cause 
a uniform and symmetrical enlargement.' They vary in consistency, 
but are often soft, so that haemorrhage is very apt to occur into 
them. They are found more often in children than in adults, whereas 
sarcomata, Avhich spring often from the membranes and are more 
apt to perforate the skull, occur more often in adults. 

The symptoms of intracranial tumour in children do not in any re- 
spect differ from those produced by like lesions in adults, except 
perhaps that owing to the more yielding state of the cranial sutures, 
and the greater frequency of tumours in the posterior fossa, obvious 
hydrocephalus is more often met with. The localizing symptoms 
are identical at all ages. The general symptoms are perhaps less 
easily recognized — headache, for instance, may be easily overlooked 
in a young child, especially if there be much somnolence. Optic 
neuritis may only develop at a late stage, and it is often very diffi- 
cult to make a satisfactory examination. Vomiting is a frequent 
and, if carefully studied, a characteristic symptom ; it comes on sud- 
denly, usually without any sense of nausea, and is not influenced by 
the usual remedies. Sometimes after lasting for a day or more it 
ceases spontaneously, to recur again after some days or weeks^l 
Somnolence — that is to say, a tendency to drop into a heavy sleep a* ' 
odd times, or to sleep heavily at night, and to be dull and heavy by i 
day — is a common symptom in children and may serve to excite 
suspicion. Convulsions occur with great readiness in children, and ' 
are usually general, or quickly become so even when at first they 

' Bernliardt, "Beit. z. Svmp, ii. Diag. d. Hirngeschwulste," Berlin, 1881. 
2 Vide Money, Med. Chu Trans., vol. Ixvi., p. 283. 



IXTRACRAyiAL TUMOUR. 479 

present the true Jacksonian limitation. In tumour of the oerebelhun, 
or so situated as to bring- pressure upon it, giddiness is usually a 
marked symptom, and the gait is peculiar — clumsy and festinating — 
owing apparently to weakness or want of coordination of the mus- 
cles of the spine, and to some rigidity of the lower extremities. In- 
ternal strabisnuis from paralysis of the sixth nerve and enlargement 
of the head due to hydrocephalus are early symptoms in many cases 
of cerebellar tumour, as is also optic neuritis, which at a comparaiively 
early stage may be accompanied by total loss of vision. General 
convulsions may occur, but in some cases, especially those in which 
the middle lobe is involved, there are attacks of tonic spasm with 
marked i*etraction of the head, and sometimes arching of the back. 
In such cases the retraction may eventually become permanent, and 
may be accompanied by marked rigidity of the muscles of the 
extremities. 

The prognosis of intracranial tumour in children is worse than in 
adults, owing to the frequency with which the growth is tuberculous, 
and the rarity of gumma. 

In diagnosis the main difficulty is to exclude functional disease. 
General convulsions may be epileptic or eclamptic, and unless optic 
neuritis or definite localizing symptoms develop, it may be impos- 
sible to distinguish the fits of idiopathic epilepsy from those pro- 
duced by intracranial tumour even situated in relation with the 
cortex, for some paresis may remain after an epileptic fit. The mis- 
take of attributing the early symptoms of tumour to hysteria is 
sometimes made ; hysteria especially in girls about the age of pu- 
berty, is sometimes complicated by complaint of headache, said to 
be severe, and by retching or vomiting. The headache is, however, 
less severe, and the vomiting less sudden and uncontrollable, and 
other hysterical symptoms will prol)ably be discoverable. The diffi- 
culty of diagnosis from intracranial abscess has already been men- 
tioned (p. 475). In tumour the symptoms are more persistent, and 
develop more steadily and more slowly, paralysis of cranial nerves 
is more often present, the focal symptoms are more defined, headache 
is more constant, and fever is usually absent. The symptoms of 
tumour may resemble closely those of tulxjrculous meningitis if it run 
a chronic course, but are usually less constant, less well-defined, and 
the characteristic stages are not to be distinguished. If a tumour in 
n lation with the cerebellum Vjccome complicated by meningitis the 

iiptoms prcKluced are those of posterior basal meningitis, and it 
Miu-t l>e borne in mind that chronic hydroce])halus maybe ])r()duced 
by tumour cerebri. 

The treatment af intracranial tumour is most unsatisfactory. Io- 
dide of jK»tassium produces amelioration or temjK)rary recession of the 
-} niptoms, even in some cases which are not syphilitic. If the 



480 INTRACRANIAL ABSCESS, THROMBOSIS, AND TUMOUR. 

growth is believed to be tuberculous the ordinary treatment for this 
infection may be advised with a certain amount of hope, as there is 
reason to believe that tuberculous growths within the cranium some- 
times remain quiescent for long periods, and even undergo oboles- 
cence. If the syniptoms point to the cortex as the seat of the tumour, 
the question of operation should be considered. For the relief of 
headache bromides are of service, as is also Indian hemp, but when 
very severe it may become necessary to give morphia or opium. 
Drugs exercise little or no influence over the vomiting, which is best 
controlled by rest in bed in a darkened room, and the administration 
of iced drinks. 



\ 



■ CHAPTER XLIII. 

HEMIPLEGIA. SPASTIC RIGIDITY. HEREDITARY 

ATAXY. 

?^^^-^ndary Hemiplegia — Congenital and Infantile Hemiplegia — Spastic Rigidity — 
Hereditary Ataxy. 

Hemiplegia in childhood, excluding cases due to tumour, abscess, 
or acute meningitis (7. r.), may be (1) secoudari/ — that is, it occurs as 
a complication of an acute specitic disease, of heart disease, or is 
produced by an injury ; or (2) it may be congenifal or acquired in 
early life (infanfilr), when it involves an arrest of development. 

Secondary hemiplegia which occurs as a complication or sequela of 
many acute diseases, including pneumonia, may be transient or per- 
manent, complete or incomplete. Hemiplegia in which the paralysis 
is well marked and permanent must be due to coarse cerebral lesions, 
and such lesions have been found in many cases after death. They 
are due either to embolism secondary to endocarditis or to cardiac 
dilatation, or to ha?morrliage produced by the disturl)ance of intra- 
cranial circulation secondary to thrombosis of a cerebral sinus. 
Hemiplegia from these causes is met with in connection with scarlet 
fever, measles, diphtheria, typhoid fever, and small-pox. I^asting 
hemiplegia, and more limited paralysis coming on in whooping-cough 
during one of the paroxysms, is due to haemorrhage produced ap- 
parently by the extreme venous congestion caused l)y the great rise 
of venous pressure which must take place towards the end of a 
paroxysm. The pathology of those cases in wliich the paralysis is 
transient is in need of elucidation. The hemiplegia of whooping- 
cough is in some cases exceedingly transient, and has been thought 
to be due to cedema, but in other cases it is permanent, or at least 
long lasting, and must be attril)Uted to a gross hfemorrliage. On the 
whole it may be said that the prognosis of hemiplegia in association 
with the acute specific diseases, if the paralysis be not complete, is 
good. Great improvement and, in cases in which the extent and 
degree of paralysis has been slight, complete recovery is frequent, if 
not indeed the rule. On the other hand, the prognosis of well- 
markfd hemiplegia in which signs of early improvement are absent 
is bad, more especially if there be commencing contracture, with 
ankle clonus and exaggeration of the deep reflexes. 
31 481 



482 HEMIPLEGIA. SPASTIC RIGIDITY. HEREDITARY ATAXY. 

In some cases improvement is rapid, and complete, or almost com- 
plete, recovery takes place. In others, the leg recovers almost com- 
pletely, but the arm is permanently affected. In others, the leg re- 
covers to a considerable extent, but there is some rigidity, and the 
patient has a hemiplegic gait. In others, again, there is well-marked 
permanent hemiplegia with rigidity. If the facial muscles are se- 
riously affected there is usually imperfect growth of that side of the 
face, and often cranial asymmetry. In those parts in which palsy 
persists late rigidity ensues, and the deep reflexes are exaggerated. 
The elbow and wrist are more or less flexed, the fingers flexed or ex- 
tended and rigid, all movements being slow, incomplete, and usually 
tremulous. The movements of the shoulder are generally more 
free, so that the hand can be placed on the head, and in some cases 
in which this cannot be done the failure is due rather to weakness 
than to rigidity. Only in a few cases is there permanent palsy with- 
out rigidity or increased reflexes. 

"With regard to the treatment of hemiplegia in childhood, it must 
be admitted that a good deal of scepticism is allowable as to the 
effect of the various means — massage, electricity, iodide of potas- 
sium, strychnine — which have been praised. Very remarkable im- 
provement may be witnessed under any form of treatment in some 
cases. This occurs, as a rule, in those in which the paralysis is not 
complete in any part. In other cases presenting definite paralysis 
no treatment is of much avail. Massage is of use in maintaining 
nutrition and preventing deformity. In some cases the use of suit- 
able prosthetic apparatus, preceded where necessary by tenotomy, 
will improve the power of walking. 

At the time of onset the treatment must be such as is appropriate 
to the condition with which the hemiplegia is associated. 

Congenital hemiplegia may be due to a lesion of one hemisphere 
occurring during intra-uterine life, involving an arrest of develop- 
ment, or to injury at birth — in almost all cases meningeal haemor- 
rhage (g. v.). If the lesion occur during intra-uterine life, the infant 
may be born with well-marked contracture of the affected side. If 
the lesion has been produced at birth there may be no symptoms to 
attract attention for some days, weeks, or months, when it is observed 
that the infant does not move the limbs on one side. In a minority 
of the cases convulsions, general or one-sided, and with or without 
retraction of the head, occur during the first few weeks of life. 
Even so the palsy may not be observed until some weeks later. The 
occurrence of epileptiform convulsions in later stages of congenital 
hemiplegia is considered under Epilepsy (g. v.). 

Acquired infantile hemiplegia which comes on before or soon after 
the age of two years is occasionally a complication of an acute spe- 
cific disease, but as a rule there is no discoverable determining cause. 



HEMIPLEGIA. 483 

The child is siezed with couviilsious, one-sidetl or general, and 
suffers some elevation of temperature. The convulsions last tor 
a few hours, or are repeated with few, and perhaps imperfect, 
remissions for several days. When they have passed away the 
child is found to be hemiplegic. In some cases, in which a 
series of tits occur, the palsy is at first slight, l)ut becomes more 
complete after each suceeeiling tit. There may be no initial con- 
vulsions, but the child is suddenly found to be paralyzed on one 
side. The pathology of cases of this nature is probably not in all 
cases the same. Syphilitic arteritis, with consequent thrombosis, 
softening, and capillary hivmorrhages, may account for some ; a 
localizeil meningitis, or meningo-encephalitis, for others. Striimpeiri^ 
suggestion that in some cases the primary lesion is an acute encepha- 
litis has received a certain amount of support from pathological 
observation,^ and accounts probably {or many of the worst cases. In 
infantile hemiplegia, whether produced by injury at birth, or by 
disease, the permanent symptoms are due to cortical sclerosis and 
atrophy. The sclerosis may be (1) widespread, involving the whole 
of one hemisphere ; (2) limited to the motor area ; (3) scattered, the 
great overgrowth of fibroid tissue producing nodidar projections ; or 
(4) associateil with cysts at the surface, or jx^reucephalus — cavities 
extending into the substance of the l)rain, and even reaching the 
""ntricle. 

In a minority of cases the paralysis, especially if from the first it 
have been inc«:>mplete and not very extensive, gradually clears away. 
More often considerable improvement occurs in the lower limb, so 
that the patient learns to walk, but has a hemiplegic gait more or less 
marked. In almost all cases the paralysis is greater in the upper 
limb. The arm is carried usually in contact with the side, the fV>re- 
arm flexed at the elbow is carried across the trunk, the wrist is flexed 
and the fingers are adducted and flexed at the metacarpo-phalangeid 
and inter-phalangeal joints. As a rule late rigidity ensues, and is 
the most marked symptom of the condition. In such cases the deep 
reflexes are exaggerated. 

The mental condition varies a good deal. Some of the children 
III as afflicted appear to be of average intelligence, more often they 
are dull and slow, some are aphasic, not a few obviously imbecile. 
In other instances epileptic seizures occur, and the mental state 
deteriorates rapidly. In a considerable proportion of awes the af- 
fected limbs become subject to involuntary movements, tremors, 
choreiform movements ( post-hem i pi egic chorea), or athetosis (see be- 
low). There is a possibility that hemiplegia coming on in infancy or 
early childhood mav be due to syphilis, and it is always justifiable to 
eive a mercurial course followed by the administration of ifnlides ; 
" Reymond, Jahrh. f. KinderhlktU., Bd. xliv., 8. 157. 



484 HEMIPLEGIA. SPASTIC RIGIDITY. HEREDITARY ATAXY. 

for even if the lesion be not syphilitic, this line of treatment may 
have a beneficial effect on the inflammatory process which it must be 
assumed is present in, at least, a large proportion of the cases. Mas- 
sage is of use in improving the nutrition of the muscles. In certain 
cases the powers of walking may be greatly improved by suitable 
prosthetic apparatus. 

Spastic rigidity. — Under this general head may be conveniently 
classed together cases of nervous disorder, usually congenital, char- 
acterized by rigid spasm of the lower, sometimes of all four ex- 
tremities, and occasionally of the neck and trunk also. 

The pathology is not the same in all cases, though in all there is 
an atrophic condition of an area, more or less wide, of the cortex. 
In some, and these are the majority, the condition is truly congenital 
and is due to meningeal haemorrhage (g. v.) occurring during the act 
of parturition. In others it is due to an imperfect development of 
the pyramidal tract. In a child born at term this tract is not yet com- 
pletely developed, and it seems reasonable to suppose that any un- 
due pressure during delivery would be liable to damage this tract in 
particular and so hinder its subsequent normal development, more 
especially if, as has been the case in a good many instances, the child 
has been born prematurely. The same woman may bear more than 
one child which suffers from spastic rigidity, though not always to 
the same degree or with the same distribution. In other cases the 
condition develops after an acute illness in early childhood. Such 
cases doubtless belong to the same category as those considered under 
the head of acquired hemiplegia. There is also an hereditary form 
which may begin later in life, even in middle age, due to degeneration 
of the pyramidal tracts. The association of spastic rigidity with 
mental deficiency, nystagmus, and atrophy of the optic nerve is due 
to a cerebral lesion, to which probably the spinal degeneration is 
secondary. Mental deficiency is, however, common in children with 
spastic rigidity who present no other evidence of cerebral lesion. 

Massolongo^ distinguishes five main clinical types, but contends 
that the difference in extent and character of the symptoms is due 
less to the involvement of different nervous areas than to the vary- 
ing period of life at which the primary lesion is produced. His five 
types are : — (1) General spastic rigidity ; (2) paraplegic rigidity ; 
(3) bilateral spastic hemiplegia ; (4) bilateral athetosis ; (5) congeni- 
tal spastic chorea. 

In general spastic paraplegia, the form most commonly seen, ad- 
vice is sought, usually, when the child is between one and two years 
old, because its legs are stiff, and it does not learn to walk. It has 
been born prematurely, and usually in a state of asphyxia, due some- 
times, but not always, to prolonged labor, from which it was with 
^11 Policlinico, vol. iv., m., fasc 1, 2. 






SPASTIC RIGIDITY 



485 



difficulty recovered. The muscles of the lower extremities are in a 
State of rigid spasm. The thiglis are rotated inwards, and brought 
into apjx>sition bv spasm of the adductors ; the knees are in contact, 
but, owing to the inward rotation, the tibife are separated by a con- 
siderable interval, and the feet are in the |x>sition of equinus. When 
a little older, the child may attempt to walk wlien supported 
under the shoulders. The foot is 

brought forward bv a semicircular Fig. 69. 

movement, during which the 
trunk is l>ent towards the opposite 
side ; but, in spite of this tilting 
of the pelvis, the toes are dragged 
along the ground. The adduction 
may be so extreme that the foot 
is brought to the orround in front 
of the other. Lastly, as the 
weight is transferred to the toes, 
the elongation of the gastrocne- 
mius causes an immediate reflex 
contraction whicli throws the 
whole body forward ; this gives to 
the gait, if the art of walking is 
ever acquired, a peculiar jumping, 
hurrying character. In mild cases, 
the upjx^r extremities escape, but 
they may l^e affected by rigidity 
to any degree, as may also the 
muscles of the neck. Indeed, in 
severe cases, all the muscles of 
the trunk may be more or less 
involved, except those of respira- 
tion. When this is the case, the 
head may be retracted, while the 
trunk is lx)wed forward. Sitting 
may be im|X)ssible, owing to the 
rigidity of the hip and trunk mus- 
cles. If it be possible, the ecjui- 
librium is unstable — the weight 
rests on the ischial tul)erosities, 
the thighs are semi-flexed on the tmnk, the knees flexed to an obtuse 
angle, and the feet held rigidly forward. Strabismus, usually con- 
vergent, is present in about one-third of the cases, and in many in- 
stances is associated with errors of refraction. Owing aj)])ar('ntly to 
-'^mie rigidity of the face muscles, the expression is stupid. Sixjcch 
_^enerally drawling and jerky, and is acquired late. There may 




General spastic rigidity; showing the attitude 
in standing. (After a drawing made by A. Dall' 
OocA BiANCA for Massoloxoo.) 



486 HEMIPLEGIA. SPASTIC RIGIDITY. HEREDITARY ATAXY. 

not be any marked intellectual defect, though the character is usually 
irritable, capricious, and often mischievous. There may be some 
difficulty in deglutition, but the sphincters are not affected as a rule, 
though, in a few cases, there is incontinence of urine. The deep 
reflexes are exaggerated, but when the rigidity is extreme, it 
may not be easy to elicit them ; ankle clonus can be obtained 
in many cases. The superficial reflexes and common sensation are 
unaffected. 

In some cases, the spastic conditions may be limited to the lower 
extremities (parajDlegic rigidity), or is very much more marked than 
in the upper limbs. In other cases, again, the paraplegic rigidity is 
combined with spastic paralysis of one upper limb (congenital hemi- 
plegia). In other cases, again, in which the condition is in its most 
pronounced form, there is congenital diplegia with spastic rigidity. 
It is in such cases that athetosis seems to be most liable to occur. 
In this condition, the limbs are subject to spontaneous involuntary 
slow movements. Thus in the upper limbs slow spasmodic move- 
ments of extension, abduction, and flexion of the fingers, of flexion 
and rotation of the wrist, of flexion and extension of the elbow, and 
of rotation, abduction, and adduction at the shoulder-joint, may be 
observed. Similar movements may affect the lower limbs. Occa- 
sionally the facial muscles are affected. The movements do not, as 
a rule, occur during sleep. They may be aggravated, or produced 
by emotion, but are not painful. The general character of athetotic 
movements is well illustrated in the following illustration (Fig. 70) 
of a case of Massolongo's. In other cases, the extremities are sub- 
ject to almost constant slow spasmodic movements, resembling those 
of chorea, whence the term congenital spastic chorea, applied to this 
condition. 

In spastic rigidity, the mental condition varies a good deal. When 
the lower limbs only are affected, intelligence may be fair ; when 
the symptoms have a hemiplegic distribution, the acquisition of 
knowledge is generally much hindered, and the child appears dull in 
intellect. In the cases in which the lesion is more extensive, the 
patients are almost invariably quite imbecile. 

The prognosis even in the mildest case is bad, inasmuch as com- 
plete attainment of muscular power cannot be hoped. In all but the 
most severe, some improvement generally takes place. The rigidity 
may, for example, disappear from the upper limbs. This result is 
favored by systematic active and passive exercise of the limbs, and 
by massage. Tenotomy may be necessary to obtain the full advan- 
tage of this treatment. In some cases, the aspect of the child, which 
suggests complete imbecility, may be, to some extent, misleading, and 
a good deal of knowledge may be imparted by a painstaking in- 
structor. 



HEREDITARY ATAXY 



48' 



Hereditary ataxy (Friedreich's Disease) is a form of ataxy which 
comes on in childhood or early life, and i< due to degeneration of the 
posterior colnmns of the spinal cord. 

It is a family disease, /. c, a disease which attacks commonly sev- 
eral members of the same generation, brothers and sisters of one 
family, althongh isolated cases may be met with. The first symptoms 
come on usually at the same age in each member of the family at- 
tacked. At or shortly before puberty is the most conunon period for 
the onset, which appears sometimes to be determined by an attack of 
measles or scarlet fever or some other acute infectious disease, but 
beyond this nothing can be said as to etiology. 

Fig. 70. 




Bilateral athetosis (congenital). 

lUSSOLOXGO. ) 



(After a drawing made by A. Dall' Occa Rianca for 



In cases examined after death the cord has always l)een small and 
has shown widespread sclerosis — in the |X)sterior columns (columns 
of Goll in their whole extent, and columns ofBurdach in their upper 
part), in the direct cerebellar tract extending laterally into the 
column of Gowers, in the lateral columns (crossed pyramidal tract), 
in the grey matter (columns of Clarke, and posterior horns). In some 
cases dilatation of the central canal has been ob.served. 

The most characteristic symptoms are those affecting the motor 
system. The patient stands with the feet far apart and has difficulty 
in maintaining his efiuilil)rium ; the IxKly sways, and the feet are 
shifted to maintain the upright attitude ; the unsteadiness may or 



488 HEMIPLEGIA. SPASTIC RIGIDITY. HEREDITARY ATAXY. 

may not be aggravated by closing the eyes. The gait is reeling, the 
steps short and uncertain ; on the whole it resembles more the gait 
of intoxication than of locomotor ataxy, in which there is much more 
incoordination. While walking or standing the head is nodded or 
moved unsteadily. In some cases there is a distinct tremor of the 
limbs and head, and choreiform movements of the same parts. 
Paresis and wasting of limb muscles may be present, and ocular 
paralyses have been observed. Sensory disturbances are rare ; 
darting pain has been present in some cases, but not anaesthesia, an- 
algesia, nor, it would seem, loss of muscular sense. The tendon 
reflexes are lost, or greatly diminished, the cutaneous unaffected. 
The movements of the pupil are not disturbed, and there is no affec- 
tion of vision or optic atrophy, but nystagmus is observed in most 
cases, though it may be a late symptom. Vertigo, permanent or 
paroxysmal, is common, and the patient may suffer from severe 
headache. Development of the intellect is not retarded, but the child 
appears stupid owing to the speech being slow and hesitating, though 
some phrases are blurted out. The expression is often heavy. The 
genito-urinary system is not involved. Lateral curvature is common 
in the late stage. A rather characteristic deformity is a peculiar 
clubbing of the feet. The foot is short, the instep high and hollow, 
while the toes are over-extended. This retraction and over-exten- 
sion of the great toe may be the first symptom of the disease to attract 
attention. In some cases loss of the knee-jerk may be observed 
earlier, but the condition of the tendon reflexes is rather uncertain, 
and their retention in the early stage would not negative the diagno- 
sis of Friedreich's disease. The reeling gait is the next symptom to 
be observed, and the unsteadiness increases until the patient, after 
perhaps three or four years, becomes unable to stand, and is hence- 
forth confined to a chair or bed. He succumbs, usually, to some 
intercurrent disease, the onset of which is favored by his inactive 
existence. Recovery is not known ever to have occurred, although 
the progress of the symptoms may show intermissions. 

Treatment, whether by drugs, electricity, or massage, has not 
been shown to exercise any influence on the course of the disease. 

Hereditary cerebellar ataxy has been described by Nonne and 
Marie. It appears to be due to imperfect development of the cere- 
bellum and cord. The symptoms, which are first observed about 
puberty, differ from those of Friedreich's disease inasmuch as the 
deep reflexes are retained and become exaggerated, Paralysis of the 
pupil to light and in accommodation and diminution of the field of 
vision due to optic atrophy are present, and common sensation is dis- 
turbed. Lateral curvature and clubbed foot have not been observed. 



II 



CHAPTER XLIV. 
LESIONS OF NERVES. 

The Motor Nervous Apparatus — Reaction of Degeneration — Birth Palsies — Facial 
Paralysis — Multiple Neuritis. 

The path of motor innervation from the cortex cerebri to the 
muscle consists of two distinct nervous structures (neurons) which 
are not in direct communication. The upper neuron is the cortical 
pyramidal cell with its dendritic processes in the cortex, and its 
axis cylinder consisting of a number of fibrils each with its separate 
destination. The axis cylinder fibrils descend in the pyramidal tract 
of the spinal cord and end in arborescent processes which interlace 
with the dendritic processes of the spinal multipolar cell, with which 
they thus come into relation, although there is no actual continuity 
of substance. The lower neuron consists of the spinal multipolar 
cell with its dendritic processes in the cord and its descending axis 
cylinder process, which ends in an arborescence by which it is 
brought into relation with the muscle fibre. The cell in either 
neuron may l>est be regarded as its centre of nutrition. Destruc- 
tion or degeneration of the cell involves degeneration of its axis 
cylinder and the arborescence by which it terminates. Destruction 
of the pyramidal cell or interruption of the axis cylinder causes de- 
generation of the part below down to the arborescence in the cord, 
and consequently the transmission of voluntary impulses from cortex 
to cord is abolished. Similarly, degeneration of the multipolar cell 
in the cord involves degeneration of the axis cylinder in the cord and 
motor nerve, and of the terminal arborescence and the muscular end 
plate. When this degeneration of the nerve reaches the muscle it is 
attended by rapid atrophy of the muscle, or of those muscular fibres 
which are in relation with the axis cylinders of those multipolar cells 
which have been damaged. We have an example of damage of the 
upper (cerebral) neuron in ordinary hemiplegia, of damage to the 
lower (spinal) neuron in infantile jjaralysis. But through the nutri- 
tion of the muscle fibres is intimately bound up with that of the 
spinal neuron, yet muscle is a mcsodermic structure and can develop 
independently of nervous impulses — a fact which explains the cir- 
cumstance that muscular fil^re is subject to certain errors of develop- 
ment and nutrition which are produced independently of lesion of 

489 



490 LESIONS OF NERVES. 

nerves. Of this event pseudo-hyper trophic muscular paralysis af- 
fords a well-known instance. 

Destruction of the nucleus of a nerve in the case of the spinal 
motor nerves, of the multipolar cells of the anterior cornu, is fol- 
lowed immediately by loss of function ; while severance, whether by 
injury or disease, of the organic connection of the nerve with the 
ganglion cells produces loss of function in the part below the lesion. 
The withdrawal of the nerve from the influence of the ganglion cells 
entails degeneration of the nerve tubules. The axis cylinder breaks 
up into smaller and smaller segments, until it finally disappears, the 
medullary sheath being destroyed in a similar manner. The process, 
which is complete in about a week, extends from the centre towards 
the periphery. If the damage to the nerve be slight, the degenera- 
tion does not affect all the fibres, and restoration of function then 
takes place more rapidly. It is a slower process than degeneration, 
but, like it, extends from the centre outwards. The axis cylinder is 
first restored, the sheath later, and conductivity may be reestablished 
before this, and before the nerve can be excited electrically. 

The degeneration of motor nerves is succeeded, in about two weeks, 
by degeneration of the muscle fibres ; they shrink, their striation is 
blurred, and they become granular. If the nerve is not regenerated 
the striation is lost and the muscular substance gradually disappears, 
while there is at the same time a growth of connective tissue, which 
generally involves some diminution of the length of the muscle as 
well as of its girth. In. lesions short of total division some fibres 
in a muscle escape, while others are totally destroyed. 

Reaction of degeneration. — In health a faradic current of suffi- 
cient strength applied to the nerve produces a continuous contraction 
of the muscle ; the galvanic, a momentary contraction when the cur- 
rent is made and broken only. When the nerve is diseased a stronger 
faradic or galvanic current is needed to produce contraction, until 
finally, when degeneration has taken place, no current which can be 
used produces any contraction. In health either current applied to 
the muscle produces contraction ; the response both to the galvanic 
current and to the faradic is quick, being in both instances due to 
stimulation of the nerve-endings. With lesion of the nerve, and 
consequent degeneration of the nerve-endings, the faradic current 
produces no contraction, but since the galvanic current is capable 
also of stimulating the muscle fibres themselves, a contraction fol- 
lows application, though more slowly than when the nerve-endings 
are healthy. After the degeneration has progressed to a certain 
stage, which is reached the earlier the more severe the case, this re- 
sponse of the muscle fibres to the galvanic current becomes more 
ready than in health. To this quantitative change is added a quali- 
tative change. In health the weakest galvanic current which causes 



; FACIAL PARALYSTS. 491 

contraction of the muscle does so when the current is made with the 
neo^ative pole on the muscle (^kathode closure contraction, K.C.C.). 
When the nervous mechanism has degenerated a contraction may oc- 
cur with as weak or with a weaker current when the positive pole 
j is on the muscle (anode closure contraction, A.C.C.), and contrac- 
tions may occur also with the same current when it is broken (anode 
opening contraction, A.O.C., and kathode opening contraction, 
K.O.C.^). To this altereii qualitative and quantitative reaction of 
nerve and muscle to the electric currents the term " reaction of de- 
generation" is applied. It is not always as definitely marked as is 
above described. When the damage to the nerve is slight the ir- 
ritability of the nerve to both currents may be retained, and the 
only evidence of the existence of a reaction of degeneration is in- 
creased muscular irritability to the galvanic curi*ent, with some change 
also in the order of contraction to the poles (qualitative change). 
On the other hand, in very chronic changes the loss of irritability 
proceeds jyari jxissu in nerve and muscle, and the reaction of degen- 
eration is not to l^e observed. 

With the regeneration of the nerve, recovery of function takes 
place, the rate of recovery depending mainly on the severity of the 
lesion. Voluntary power is first regained, then the galvanic reac- 
tions become normal, and, lastly, the faradic. 

Anaesthesia, which is the eventual result of degeneration of a sen- 
sory nerve, may l)e preceded by a condition of hypenestlicsia. The 
aniesthesia is often incomplete, especially in the hands and face ; in 
a mixed nerve, a lesion, capable of producing paralysis of motion, 
may be accompanied by little loss of sensation. Trophic changes 
seem seldom to occur in children as an accompaniment of lesions of 
sensrtry nerves. 

Birth palsies. — Certain nerves are liable to injury during the act 
of birth. Thus the facial may be damaged by the direct pressure of 
one blade of the forceps, or may be compressed by extravasation into 
the parotid. The brachial plexus may be injured l)y traction made 
by the finger or blunt hook, or by compression of the shoulders 
in dystocia. 

Facial paralysis may be due to cLimage to the conducting tract 
alnne the nucleus in the pons (see " Hemiplegia"), or to damage of 
the nucleus or trunk of the nerve. It is occasionally observed as 
part of diphtherial palsy. Meningitis of the base may involve the 
facial along with other cranial nerves. The two chief causes of facial 
paralysis in infimts are injury during parturition and middle-ear dis- 
ease. Paralvsis from cold is very rare in young children, but is not 
very uneommon after the tenth year. Facial ])aralysis may also be 
sf-fondary to adenitis, the trunk being compressed by the enlarged 
»The normal order is : K.C.C., A.C.C., A.O.C., K.O.C. 



492 LESIONS OF NERVES. 

glands, or perhaps involved in the inflammatory process, or at a later 
stage, distorted by cicatricial contraction after suppuration. 

Facial paralysis, associated with extravasation into the parotid, is 
of short duration, and, as a rule, that due to pressure by the forceps 
recovers within two or three months ; but in a few cases the injury 
has been severe enough to cause degeneration and permanent paraly- 
sis, with defective development of the face on the affected side. 
Congenital paralysis of the facial, not due to injury, has also been 
seen ; it is permanent, but its pathology is unknown. 

Lesion of the nucleus or trunk of the facial nerve is followed 
in a few hours, or, at most, a couple of days, by loss of tone 
and movement of all muscles of the face. The loss of tone is 
not so perceptible in a child as in an adult, owing to the greater 
plumpness and elasticity of the cutaneous structures, but the par- 
alysis is evident when the child laughs or cries. In emaciated in- 
fants, the loss of tone is marked. When the attempt is made to close 
the eye, the eyeball is rolled up but the eyelids are not closed, nor 
are they closed in sleep. Except in marasmic infants, the lower 
eyelid does not fall away from the globe as in the adult, and for this 
reason the overflow of tears may not be very noticeable. Owing to 
the paralysis of the buccinator, curd and scraps of food are apt to 
accumulate between the jaws and the cheek, and so to cause stoma- 
titis. Facial paralysis, associated with middle-ear disease, is of bad 
prognosis in infants. They are, as a rule, marasmic, many succumb 
to tuberculosis, and it seems not improbable that the ear disease may 
be tuberculous from an early stage, if not from the first. The prog- 
nosis of facial paralysis following exposure to cold or produced at 
birth is good ; the degree of paralysis may not be the same in all 
parts when the patient comes under treatment, since recovery begins 
earlier in the upper than in the lower. Slight cases may recover 
completely in a fortnight, but the average duration is two or three 
months. When of longer duration, contracture of the muscles of 
the paralyzed side ensues, and by causing the naso-labial fold to de- 
velop prematurely, produces a deformity of the face which may last 
long. 

The treatment of facial paralysis, due to middle-ear disease, must, 
in the first place, be directed to the cure of that condition. The 
only effectual treatment for the paralysis itself is by electricity. 
For the first week, the faradic current should be used to the muscles 
themselves ; subsequently it may be supplemented by the galvanic 
current, but the use of the faradic current should be continued two 
or three times a week so long as the movements remain defective. 
Counter-irritation is probably quite useless. 

Children are subject to the various forms of paralysis usually at- 
tributed to multiple neuritis. The lesion is produced by toxic bodies. 



m FACIAL PABALYSIS. 493 

either such as are intrcxluced into the body bv accident (arsenic, 
lead) or design (arsenic, alcohol), or such as are produced during 
various diseases — for example, the acute specific diseases (7. v.). 
Though the main stress of the toxic influence falls on the nerves, 
there is practically no doubt that the whole neuron suffers, and that 
the cells of the spinal cord do not escape. The characteristic symp- 
tom is the ass<X'iation of motor with sensory paralysis. The paraly- 
sis is usually symmetrical, and atlects all four extremities to a greater 
or less extent. It would apjx'ar that certain groups of muscles are 
more readily affected by these chronic forms of poisoning than others. 
The extensors of the wrist and of the foot are those most often at- 
tacked, so that wrist-drop and foot-dn>p are common symptoms. 
Pain in the area of distribution of the affecteil nerves, due to in- 
volvement of sensory fibres, is common ; and in some cases the nerve 
trunks are swollen and a little enlarged. The persistence of such 
pain, and especially the detection of enlargement of the trunks, are 
important points in diagnosis. The deep reflexes are almost invari- 
ably diminished or lost, usually before the paralysis develops. All 

I forms of sensation become diminished. The electrical reactions are 

I very variable, but wasting of the muscles is usually an early symp- 
tom. The paralysis and wasting may be attended by contracture, 

1 and the production of various deformities, especially talipes equinus. 

. When recovery has commenced sensation returns, as a rule, at a much 

' earlier date than the recovery of muscular power. 

The main point in treatment is to recognize and remove the cause. 
During the early stage, when pain is a prominent symptom, warm 
baths and warm applications to the part give relief. Later, when 
paralysis l>ecomes evident, the galvanic current should be used with- 
out delay, and later still, gentle massage and regulated or rhythmi- 

! cal exercises are valuable. 



CHAPTER XLV. 
AMYOTKOPHY. 

Muscular Atrophy — Infantile Paralysis — Progressive Neural Muscular Atrophy — • 
Primary Muscular Dystrophies — Pseudo-hypertrophic Muscular Paralysis. 

Paralysis attended by or dependent on degeneration of muscu- 
lar fibres may be due to lesion of the nervous mechanism which sup- 
plies the muscles, or to primary lesion of the muscles themselves. 
The first group has been further divided into those dependent on 
changes in the anterior cornu and those due to lesion of motor nerves. 
The number of varieties of chronic amyotrophic disorders described 
is very large. The distinctions recognized are in the main founded 
on the anatomical distribution of the paralysis. It is probable that 
the classification and relations of diseases of this group will shortly 
undergo modification, but for the present, however, it will be con- 
venient to retain the classification into three types — 

Primary lesion in cord Anterior poliomyelitis. 

(a) Acute infantile paralysis. 
(6) Chronic progressive mus- 
cular atrophy ( Aran- 
Duchenne). 
Primary lesion in nerve Progressive neural muscular atro- 
phy ( Charcot-Marie-Tooth ). 
Primary lesion in muscles (primary mus- 
cular dystrophies ) Muscular pseudo-hypertrophy 

( pseudo - hypertrophic paral- 
ysis). 
Juvenile form of progressive mus- 
cular atrophy (Erb's). 

Infantile paralysis is an infective disorder seldom or never en- 
countered after childhood. The characteristic lesion is rapid degen- 
eration of the motor cells of the anterior horns of the connected motor 
nerves and nerve-endings, and atrophy of the muscles supplied by 
these nerves. 

The etiology of the disease is obscure. It has occurred occasion- 
ally in epidemics, and the symptoms at the time of onset — that is, 
at the time when in the most typical cases the damage to the nervous 
structures is produced — resemble those of an acute infectious disease, 
but infection from one case to another has never been traced. The 
lesion of the cord and nerves is due, probably, either (a) to a microbe 

494 



ISFAXTILE PARALYSIS. 495 

having a special affinity to the nervous system, or, (6) as seems more 
in agreement with all the eiroumstanees, it is due to the ]>oisouous 
action of some product of microbial activity elsewhere in the body, 
which produces its most marked structural eflect on the delicate and 
growing nervous structures of the child, inducing detinite degenera- 
tive changes. Paralysis having the same characters is an occasional 
complication of various acute sjx^cific diseases. 

The distribution oi^ the lesion in the sj)iual cord proves almost cou- 
clusively that the cause is vascular. It is an acute cellular degener- 
ation (myelitis^, limited in extent both in the vertical and in the 
horizontal planes. The focus of the myelitis is in the anterior cornu 
on one side, but it may extend slightly into the white matter of the 
autero-lateral column. AVithin the focus the large motor cells un- 
dergo granular degeneration, and either disappear altogether or 
become converted into rounded masses without processes. The nerve 
fibres also undergo granular degeneration. The blood-vessels are 
dilated, sometimes thrombosed, and proliferation occurs subsequently 
in the nuclei of their walls. Later, changes of cicatricial nature take 
place. In the affected region the diseased side of the cord is smaller 
than the healthy. This is due in part to the destruction of nervous 
elements and contraction of fibrous tissue in the anterior cornua 
and adjacent part of the antero-lateral column, and in part to associ- 
ated defective development of other portions of the cord at the level 
affected. The extent of this area in the vertical direction varies 
from about a (piarter of an inch to one inch. AVhen more than one 
limb is affected, there may be two or more such areas of shrunken 
cord. 

The symptoms of the disease fall into three stages : — Onset, re- 
gression, and the stationary stage, or stage of deformity. 

The onset is attended as a rule by fever, gastro-intestinal disturb- 
ance, and nervous symptoms. There may be somnolence or coma, 
excitement with clonic spasms, or general convulsions. Death may 
occur at this stage owing to the respiratory centre being involved. 
In some cases there is considerable pain in the limb generally referred 
to the joints, but often there are no obvious localizing symptoms. 
Either during the febrile stage or, more commonly, as it subsides the 
child is found to be paralyzed more or less extensively. The paral- 
ysis mav affect one lower or uj)per extremity, or both lower extrem- 
ities, or one upix*r and one lower extremity on the same or opjiosite 

les, or all four limbs. In other cases the onset, though sudden, is 
iiMt attendeil by marked constitutional symptoms, the child being 
merely found, when taken up in tJie mr)rning, to be j)aralyzed in one 
limb. 

The stage of rer/ression begins in a few days. The complete j>aral- 
ysis of a limb or limbs begins to clear up, and at the end of a week 



496 AMYOTROPHY. 

or a fortnight some power has been regained in all the muscles of the 
limb except those of which the nervous connections have been per- 
manently damaged. In a few instances complete spontaneous re- 
covery takes place, but in the ordinary course certain muscles remain 
paralyzed, as is shown by the attitude of the limb and by the inability 
to perform certain movements. These muscles waste rapidly, and 
their electrical reactions are found to be altered. Faradic irrita- 
bility is lost rapidly after the onset, and those muscles which are 
to be permanently paralyzed do not, a fortnight after, respond at all 
to the current. The affected muscles on the contrary react very 
readily to the continuous current, and present the reaction of de- 
generation. There is often a good deal of pain in the limb at this 
stage, and the joints may be hot and tender, but cutaneous sensation 
is unaffected. 

The stage of deformities follows gradually upon that of regression. 
The wasting of the affected parts becomes very conspicuous, the limb 
is constantly cold, and its general nutrition suffers. It grows less 
rapidly than the sound limb, the bones are not only shorter but 
slighter, and perhaps more fragile. The skin is easily damaged, and 
is particularly liable to become the site of chilblains. Local oedema 
is easily induced by a dependent attitude frequently assumed, or by 
the pressure of garters, and cyanosis and mottling of the surface on 
the least exposure afford further evidence of defective circulation and 
nutrition. The amount of subcutaneous fat may be somewhat exces- 
sive (^^subcutaneous adiposis,'^ "local obesity ''), but more often it is 
deficient. 

The distribution of the paralysis is governed by functional, not by 
anatomical relations. Thus the supinator longus is affected along 
with the biceps, brachialis anticus, and deltoid (" the upper arm 
type ^' of Eemak), while in the so-called " forearm type '^ the triceps 
is paralyzed, but the supinator longus escapes. In the " lower arm 
type " the extensors or flexors of the wrist and fingers are paralyzed. 
In the lower limb the peroneal group of muscles is that most fre- 
quently affected, then the posterior tibial, next the quadriceps in as- 
sociation with the tibialis anticus — muscles associated in the extension 
of the leg in walking. The glutei and the hamstrings are not often 
affected, the muscles of the face very rarely ; the sphincters escape 
even at the height of the disease. Nearly all the muscles of a limb 
may be affected, so that the leg, for instance, is flail-like, and quite 
useless. 

The treatment of infantile paralysis is usually regarded as a some- 
what hopeless task, inasmuch as those muscles which are supplied 
from the parts of the cord where the lesion is most intense become 
more or less completely paralyzed and atrophied, while those supplied 
from parts less severely damaged recover spontaneously. It is reason- 



IXFAXTILE PARALYSIS. 497 

able to assume, however, that the lesion in the cord is, in all parts which 
are at all aifeoted, the same in kind, thouixh it differs in degree ; and 
further, that the axis eylindei-s and the end plates suffer at the same 
time. It is usually held that no treatment directed to stimulate the 
activity of the cord and nerves is permissible in the early stage. It 
may be argued, however, that as the nervous structures are extravas- 
cular the fear of exciting or maintaining iutiammatory action in their 
neighborhood by stimuli, such as electricity, which intiuence only 
or chiefly the nervous structures, need not be entertained. This 
view has been energetically defended by Cagney,' who argued further 
that since the peripheral ending of the motor nerve besides j)artici- 
pating in the degeneration of the spinal cell, is, in virtue of its own 
blood supply, still further involved in the toxaemia which is the as- 
sumed cause of the disease, it would follow that a peripheral neuritis 
is sui>eradded to the changes in the cord, the part most affected in 
the toxiemia. If this be so, it is justifiable to endeavor to maintain 
the nutrition by stimulation applied to the periphery from a very 
early stage. Even if these views be not accepted to the full, it must, 
I think, be admitted that the fear of increasing the damage to the 
nervous elements has been made rather a bugbear. In whatever light 
we regard the primary lesion in the cord, it will not be denied that 
it reaches its maximum in a ver}- short time, for the stage of febrile 
reaction is short and is, indeed, not always present, and that regression 
of the paralytic symptoms — that is to say, the recovery of the anterior 
cornua at those levels which have been primarily affected to a lesser 
degree — Ijegins in a few days. 

If the patient is seen during the febrile stage a dose of calomel 
should be given at once, and the same drug should be j)rescribed in 
small doses for some days. Belladonna and ergot botli have their 
advocates, but it is doubtful whether they exert any influence on the 
course of the disease. The patient should be kept warm, and, if 
possible, in bed in the recumbent attitude. Cagney, in accordance 
with the principles indicated al)ove, advocated tlie employment of 
weak galvanic currents, massage of the affected liml)s, and injections 
of str^'chnine from the earliest stage. He maintained that the pros- 
pect of recovery depends upon the promjHitude with which these 
measures are undertaken. He informed me that in some severe 
cases, in which under the expectant treatment a large remnant of 
permanent paralysis was to l>e looked for, complete recovery <tf func- 
tion was eventually obtained. The affected muscles a)ntinue to dis- 
play the galvanic reaction of degeneration for many months, and he 

' His contention is stated briefly in a note of a paper crmtainefl in the BrUish 
M'fliral JournnJ, 18%, vol. ii., p. loO'i. The Iainent<-<1 «lcath «»f I)r. Carney mjiirred 

*^>ile thesHJ pa^es were L'"i"'-' ''"■""'-''' 'Ji<- nri-— .-nirl In- Im- Irft ii(» furflwr piilili-h«<l 
•rd of his experienc* 

32 



498 AMYOTROPHY, 

looked on the persistence of this phenomenon as a hopeful sign, and 
as an indication for the continuance of treatment. At the same time 
the patient should take fatty foods, cod-liver oil and extract of malt, 
and other foods and digestives which maintain nutrition. The af- 
fected limbs should be kept wrapped in cotton-wool. The amount 
of strychnine injected should be at first ^^-^ of a grain (of the ni- 
trate). Cagney injected it into the substance of the affected muscles 
daily, and attached considerable importance to this. He increased 
the dose gradually to as much as -^-^ or even -g^ of a grain. The 
affected muscles should be galvanized daily, using the current of 
from 10 to 20 cells ; at the commencement of treatment the posi- 
tive pole should be applied locally, afterwards the two poles alter- 
nately. 

At a later stage massage is most useful, and should be continued 
throughout the whole period of growth. It is often said that after 
the expiration of one year from the onset no further improvement 
can be expected. Even if this be true, it is certain that deteriora- 
tion may take place if the muscles are not used. This wasting and 
loss of power may undoubtedly be checked by massage well applied, 
and faradic electricity is also of some use for the same purpose. 
Massage further has the effect of improving the circulation through 
the limb generally, and thus tends to maintain growth and to pre- 
vent the shortening of the limb, which is often one of the main 
causes of extreme lameness. 

The immediate effect. of massage on the muscles manipulated is to 
cause an increased flow of blood through them.^ When the massage 
is stopped there is a momentary accumulation of blood in the muscle 
substance, followed by a greatly increased flow. The effect of mas- 
sage of a group of muscles is, in its influence on the local circula- 
tion, analogous to that of the contraction of the same muscles. The 
effects of massage on the general circulation of a considerable mus- 
cular area are to produce a lowering of peripheral resistance in the 
area, and as a consequence of this more blood is propelled at each 
heart beat from the arteries into the veins, with an attendant fall in 
arterial tension. 

Prosthetic apparatus suitably adjusted may be of very consider- 
able use in improving the power of walking and in checking the 
increase or production of deformities. It should be as light as pos- 
sible in construction. Before it can be properly applied it may be 
necessary to perform tenotomy. 

Progressive neural muscular atrophy, often spoken of as the 
peroneal form of muscular atrophy, begins as a rule in the lower 
extremities. The usual course of symptoms is that weakness fol- 
lowed by atrophy affects first the extensor muscles of the toes, then 
^Lauder Brunton and TunniclifFe, Jour, of Phys., xvii., p. 365. 



PBIMARY MUSCULAR DYSTROPHIES. 499 

the small muscles of the foot, then other muscles of the lower ex- 
tremities. The two IciTS are attacked almost sinuiltaneously, or in 
rapid succession, and eventually talipes equinus or equino-varus is 
produced. The atrophy may involve the muscles of the upper ex- 
tremities and may even begin in them, but the leg:s are always in- 
volved early and to a greater degree. Sensory changes also occur, 
especially hyperalgesia, but tactile sensation and the tenq>orature 
sense may also be affected. The rcHexes in the parts affected are 
diminished or lost. The electrical reactions are diminished and 
altered qualitatively. 

The disease runs in families, and begins usually at a very early 
age, so that clubbing of the foot may be well marked at the age of 
five years. 

The diagnosis must rest upon the presence of double club foot, 
which is not congenital, upon the sensory disturbances, and upon the 
slow onset and progressive character of the atrophy. As has been 
said, the primary lesion is apparently in the nerve trunks, although 
it is probable that this view might require modification in the future. 

Primary muscular dystrophies occur under several clinical forms, 
which all agree in that, with rare exceptions, they commence in 
childhood or youth, and are in many instances family diseases — that 
is, they are hereditary, or affect several members of the same family. 
They differ in their point of origin, and the distinction between the 
clinical types depend in part upon this. Thus the atrophy may be- 
gin (a) in the face and extend after a time to the shoulder girdle 
and upper arm — the jaj<cio-scajjulo-humcra( type (Dcjerine-Lan- 
douzy) ; or (6) it may begin in the shoulder girdle and extend to 
the upper arm and, finally, to the lower limb — the "jureni/c mu.s- 
cular atrophia''' of Erb ; or (c) it may first attack the muscles of the 
lower limb or pelvis — the " hereditary muscular atrophy" of Leydcn 
and Moebius, and pseudo-hypertrophic muscular paralysis. They 
differ also in the effect of the disease on the bulk of the muscles. 
In some forms, pseudo-hypertrophic paralysis as a rule, and juvenile 
muscular atrophy as an exception, the bulk is obviously increased 

ing to overgrowth of the connective and adipose tissue. The oc- 
lurrence of true hypertrophy of the muscular fibre is denied by some 
authorities, but it is probable that in some (juvenile form of Erb), 
and possible that in all, it is the first change which occurs. Next 
there is proliferation of the connective tissue, with or without de- 
posit of fat, and finally there is complete disapi>ear»nce of the mus- 
cular tissue, though the bulk of the muscle may be maintained or, 
as in pseudo-hypertrophic paralysis, greatly inereascd. P^ventually, 
however, even in this type, the fat is absorbed, and the atrophy of 
the muscles becomes evident to the eye. I^ng before this the atrophy 
of raascular fibre is shown by loss of power and by the disappear- 



500 AMYOTROPHY. 

ance of mechanical and electrical irritability and of tendon reflexes. 
The reaction of degeneration is not present, and there are no fibril- 
lary twitchings. 

The pathology is obscure. There is no evidence of any change 
in the cord, and the suggestion that the primary defect is a tropho- 
neurosis appears to be negatived by the fact that in the same mus- 
cular bundles some of the fibres may be atrophied, others perhaps 
hypertrophied, and others unaltered. If the change was a tropho- 
neurosis it would be reasonable to expect all fibres innervated from 
the same cell or group of cells to suffer alike. Further, the distri- 
bution of the paralysis is not the same as in disorders known to be 
due to spinal lesions. The fact that the atrophy affects commonly 
several members of the same family in the same or in succeeding 
generations, and the further fact that it begins in early life, lend 
support to the view that the primary defect is in the muscle fibres. 
While the nerve-cell and nerve are derived from the ectoderm, the 
muscle fibre is derived from the mesoderm and may develop without 
structural abnormality in the absence of any nervous connections. 
Though the life of a muscular fibre appears to depend on the in- 
tegrity of its connection with a healthy multipolar cell, this, ob- 
viously, does not preclude the possibility of its presenting some in- 
herent vice of constitution. 

Pseudo-hypertrophic muscular paralysis is the best known and 
probably the most frequent type of myopathic atrophy. It affects 
males four times more frequently than females, but w^hen heredi- 
tary transmission can be traced, it is through the mother. The dis- 
ease may manifest itself at any time after infancy, in one-third of the 
cases when the child first attempts to walk, in one-third between the 
fourth and sixth year, and altogether in three-fourths before the tenth. 
The parents notice that the child, who has, perhaps, learnt to walk late, 
walks clumsily, often falls, and has great difficulty in getting up- 
stairs. Enlargement of muscles is seldom noticed in children under 
five. The affected muscles are not only large but extremely hard, 
and do not become much softer when relaxed. The enlargement is 
commonly first seen and is most conspicuous in the calves. The ex- 
tensors of the knee (rectus and vasti), the glutei, and the lumbar are 
often enlarged. Of the muscles of the upper limb the infra-spina- 
tus is most often enlarged, the deltoid sometimes, and the muscles of 
the arm in diminishing degree from above down. The latissimus 
dorsi and the lower part of the pectoralis major do not enlarge, but, 
owing either to atrophy or failure in development, are often absent 
when the case is first seen. The absence of the posterior fold gives 
a peculiar appearance to the axilla. Most of these points are 
illustrated by the photographs reproduced in Figs. 71 and 72. 
As a rule, the muscles of the neck and face escape. The degree 






PSEUDO-HYPERTROPHIC MUSCULAR PARALYSIS. 



501 



not directly related to the degree of enlaroe- 
developed disease the child rises 



earlv stage of the 



of muscular pals> 
meut. In the 

from the ground in a characteristic way. He first gets on his 
hands and knees, then he spreads the hands and knees as far a^>i\rt 
as possible, throwing the weight on the hands ; then, getting the toes 
on the ground and swinging the body back, he gets the knees ex- 
tended, and ''walking" the hands along the floor throws part of the 
weight of the body on the legs ; lastly placing one hand on one 
knee, he pushes with the other off* the ground, throwing the weight 



Fig. 71. 



Fig. 72. 





udohj-pertrophic paralysis, showing "hypertrophy " of sonic, and atropliy of «.tlier nuisclcs. 
(From a photograph by Dr. Percy C. Phillips.) 

; the lx)dy back and so extending the hip. At the .same time he 
supplements the advantage thus gained by pressing with the hands, 
wiiich are shifted alternately up the thighs. 

The order and degree in which tlic muscles of the lower ]iinl>s are 
affected appears commonly to be — flexors of hip (]).-^as and iliacus), 
extensors of knee (rectus and vasti), exten.sors of hip (gluteus max- 
imus mainly). 

The difficulty in getting up stairs is due to the weakness <»f the 

tensors of the hip and knee. In walking, tiie pelvis osrillates 

widely, being tilted with each pace so as to bring the centre of 



I 



602 AMYOTROPHY. 

gravity over the foot which is on the ground. This is done owing 
to the weakness of the hip muscles, and in particular because the 
gluteus medius is too weak to counteract the tendency of the pelvis 
to tilt towards the side on which the foot is oiF the ground. 
Another effect of the weakness of the extensors of the hip 
is lordosis on standing, owing to the pelvis being tilted forward ; 
to bring the centre of gravity over the feet, the upper part 
of the trunk is carried backward, so that a line dropped from the 
scapular angle falls well behind the sacrum. When the child sits 
down the lordosis disappears, and is replaced by curvature in the 
opposite direction, owing to the weakness of the spinal extensors. 
The peculiar manoeuvers practised in rising from the ground are de- 
signed mainly to replace the diminished power of the extensors of the 
knee. When these muscles are entirely destroyed the patient cannot 
rise or stand. Increasing weakness of the muscles of the back ren- 
ders him unable to sit up, and when placed in the sitting posture the 
trunk bends forward, producing extreme posterior, often combined 
with some lateral curvature. The shortening and atrophy of muscles 
lead to various deformities of the limbs, commonest and earliest 
among which is talipes equinus, due to the shrinking which succeeds 
the overgrowth of the calves. 

The prognosis is bad, for the child usually succumbs, at about or 
before the age of puberty, to bronchitis or some other intercurrent 
malady. The duration of life is likely to be longer the older the 
patient is when the disease is first observed. In a few cases the 
disease appears to have been arrested — at any rate for some time ; 
and the prognosis is on the whole better in girls than in boys. 

The diagnosis of the disease is generally not difficult — the age of 
the patient, the progressive loss of power, the peculiar gait the 
lordosis on standing, and the peculiar manner of rising from the floor, 
will suggest the disease, and the detection of enlarged and hardened 
muscles (especially the calves and infra-spinati) will confirm the 
diagnosis.^ The distinction from other types of myopathic atrophy 
depends on the distribution of the palsy and the enlargement of the 
muscles, but cannot always be made. The absence or great diminution 
of the knee-jerks, the peculiar way of rising from the ground, the 
gait, and the passive nature of the contracture ought to prevent the 
disease being confounded with spastic paraplegia. 

Treatment can do nothing to arrest the progress of the disease. 
Arsenic and phosphorus have been thought to have some beneficial 
effect, but their influence is doubtful, since the disease, though on the 
whole progressive, may spontaneously present intervals of arrest or 
much retarded progress. Electricity may be of some service in 

' Enlargement of the infra-spinatus, with disappearance of the latissimus and the 
lower part of the pectoralis, Gowers regards as almost pathognomonic. 






PSEUDO-EYPERTROPHIC MUSCULAR PARALYSIS. 503 

stimulating growth, and massage in improving nutrition, but the 
voluntarv stimulus is the most effectual. Gymnastic exorcises are 
therefore to be recommended. The contraction of the calf muscU^s, 
and tlie consequent equinus which may prevent the patient from 
walking at an early stage of the mahidy, may be remedied by 
tenotomv. 



CHAPTER XLVI. 
DISEASES OF THE SKIN. 

Urticaria — Urticaria Papulosa — Raynaud's Disease — Prurigo — Urticaria Pigmentosa 
— Erythema Simplex — Erythema Intertrigo — Erythema Scarlatinif orme — Ery- 
thema Multiforme — Purpura — Peliosis Eheumatica — Chilblain — Pemphigus — 
Herpes — Pruritus — Itching ; Pediculosis ; Scabies. 

Angeio -neurosis. — The cutaneous structures are liable to vaso- 
motor disorders in which the mucous membranes and, perhaps, certain 
of the viscera may also share. 

Urticaria is the most common and typical example. Under the 
influence of various causes, of which the most important and frequent 
are digestive disturbances, a localized oedema of the skin develops 
rapidly owing, probably, to paralytic dilatation of the arterioles. 
The resulting swelling, or wheal, has a white centre with a red 
border. As the oedema subsides the centre becomes red, while the 
white color extends to the edge. The size and number of the wheals 
vary very much. They may be large, and then generally few in 
number, or numerous and small. Their appearance is attended by a 
great deal of itching and discomfort, and the child is often a little 
feverish. The wheals when small are often very evanescent. When 
large they usually last a few hours, and then fade, leaving a slight 
redness of the skin, which disappears in a few hours. When at their 
height the wheals are firm, but if placed on or near parts with much 
loose connective tissue, such as the eyelids or scrotum, there may be 
extensive oedema, producing much deformity of the part. In rare 
cases no distinct wheal forms, but a more or less extensive surface 
becomes oedematous. The face, lips, cheek, hands, or legs may be 
attacked. The oedema is tense, and there may be some itching be- 
fore it is fully developed. Sometimes the attacks recur periodically 
and even at the same hour on many succeeding days. The tendency 
to this condition occasionally runs in families. In many cases the 
outbreak is attended by colic and other symptoms of gastro-intestinal 
disturbance. As a rule the child ceases to be troubled by the attacks 
after some years, but the liability may continue for an indefinite 
period, and death has been produced by sudden oedema of the larynx. 
In children the most important form of urticaria is that to which the 
term urticaria papulosa has been applied by Colcott Fox. The con- 

504 






URTICARIA. 505 

clition, which was formerly oalknl lichen urticatus, causes verv oreat 
distress both to mother and chiKl, since the irritation it ])ro(hices 
prevents sleep and keeps the child continually restless — " always on 
the fidget." The individual wheals are small and at fii'^t evanescent. 
After a time there are, mixed with the ordinary wheals, others with 
a hard central papule, which does not disappear as the wheal sub- 
sides, but remains as a red point when the color is tlischar;»:ed from 
the rest of the wheal by pi-essure. The papules itch intensely, and 
by scratching become infected. They then become crowned by small 
pustules, which are succcedeil by scabs. The jKipules ajipear on all 
parts of the body, es[>ecially upon the trunk, forearms, and calves. 
In severe cases the child or infant may be covered almost from head 
to foot with papules, jnistules, and scabs. 

Among causes of urticaria, the first place may be given to local 
irritants, since the disease owes its name to the nettle, which pro- 
duces typical urticaria on a small scale. Many insects which attack 
man also produce local urticaria. The most important causes, how- 
ever, are poisons derived from the gastro-intestinal canal. These may 
be ingested. Mussels and other kinds of shell-fish, for instance, in- 
variaV^ly pnxluce an attack in some persons ; in other cases, the 
poisonous quality of the food is due to some change of the nature of 
decomposition, which has taken place in it. In other cases, and 
these are in practice the most important, the toxic substances are 
]iroduc€xl during digestion, owing to some defect in that ])rocess. 
I'rticaria pa])ulosa is, in many cases, associated with dilatation of the 
.-tomach ; in others, with chronic and intestinal catarrh ; but, in others, 
the infants are well nourished, and present no symptoms beyond, at 
most, a little flatulent dysi>epsia. In fact, in all forms of urticaria de- 
pendent on digestive disorder, idiosnycrasy plays a very large part. 
Urticaria papulosa may occur at any time of the year, but is us- 
■mlly worse in warm weather. In many, perhaps the majority of 
ises, attacks recur again and again for years, and, according to 
Malcolm Morri-, may Ik? the first stage of true prurigo. 

In the treatment of urticaria pa])ulosa, the most serious fi)rm of 
urticaria in the young, the first indication is to allay the itching and 
prevent scratching. A warm or rather hot bran, starch, or alkaline 
bath should be given, or a plain bath with the use of superfatted 
menthol soap, and the body should be fpnCkly dried by dabbing with 
a soft towel. 

[Bran Bath. — Take 2 oz. bran for each gallon of water, enclo.se it 
lor>sely in a muslin bag, and allow it to soak for 10 minutes; stir 
tiie water with the bag, and remove. 

Starch Bath. — Potato starch, l oz. to each gallon of water. 

Linseed Bath. — Linseed meal, J oz. to each gidlon of water. 

Alkaline Bath. — Sodium bicarbonate, J oz. to each gallon of water. 



506 DISEASES OF THE SKIN. 

About 1 drachm of borax for each gallon may be added with advan- 
tage in many cases. Appendix.] 

The garment put on next the body should be of fine cotton, and 
should be well powdered with starch powder. If the itching returns 
quickly, as it commonly does on exposed parts of the body, these 
should be dabbed with an antiseptic and sedative lotion, or with 
calamine lotion, or an evaporating lotion. 

[Lotio Calaminae — 

Calamin. Prseparat., gr. xl 

Zinci Ox., gr. xx 

Glycerin., 9 

Aq., ad 5J- Appendix.] 

If the papules are suppurating on the surface, or covered with 
blood or crusts, the parts thus affected should be treated with an 
antiseptic ointment, for which purpose nothing is better than a weak 
sulphur ointment. Equal parts of sulphur and zinc ointments and 
vaseline make a good application, or the zinc ointment may be re- 
placed by carbolic acid ointment. A simple boric acid ointment 
with a basis of equal parts of lanoline and olive oil is also a useful 
application, to which cocaine (gr. x to vaseline oj), or carbolic acid 
(gr. XX to Sj), or both, may be added. The most important point is 
the treatment of the attendant gastro-intestinal disturbance. A dose 
of castor oil should be given at once and followed by saline aperients 
for several mornings, or by a castor-oil mixture if the stools contain 
much mucus. The best results are obtained by long-continued use 
of intestinal antiseptics, especially calomel or salol. To allay the 
itching produced by mosquitos, bugs, and other insects, ointments 
containing cocaine, carbolic acid, or ichthyol will be found useful. 
Urticaria due to ingesta must be treated, if the case is seen early 
enough, by giving an emetic, and in any case by a brisk purgative. 
Occasionally urticaria produced by shell-fish is attended by serious 
general symptoms of nervous depression, and in such cases the 
stomach should be washed out without delay and a purgative given. 

Raynaud's disease is characterized by capricious attacks of defec- 
tive circulation in parts — fingers, toes, ears, and nose — most remote 
from the centre of the circulation, and most exposed to the influence 
of cold. It is due to vaso-motor disturbance, which produces first 
contraction and then paralytic dilatation of the small arteries and 
arterioles. The disease may commence as early as the end of the 
second year, and the attacks usually recur many times in each winter, 
the patient being free during summer Aveather. 

The symptoms vary in intensity. After exposure to cold, after 
emotional disturbance, or without obvious cause, the fingers or toes, 
the parts most often affected, become " dead,'' cold and pale. This 






PRUEIGO. 507 

stage of local syncojK? is followed by roaotion, ihiring which the 
fingei-s are hot, red, and tingliiiir : or by local asphyxia, in which the 
aifected parts become intensely congested, aHleniatous, cold, and 
deep red or purple iu color. lu the former case there is a true 
reaction with increased flow of blood thi*ough the parts ; in tlie lat- 
ter, almost complete arrest of the capillary circulation, with venous 
digestion. 

Local asphyxia may be so intense and persistent that (jnnijrenc 
ensues. It is usually more or less symmetrical, and affects, espe- 
cially, the tips of the fingers and toes, the edge of the ears, more 
rarely patches of skin on the limbs or trunk. These severe attacks 
are accompanied by acute pain, but, as a rule, though the local as- 
phyxia may involve nearly the whole of the hands and feet, the part 
which actually becomes gangrenous is small. In rare cases gangrene 
may rapidly involve hands and forearms, feet and legs. Ankylosis 
of the phalangeal joints has occurreil, and peripheral neuritis has 
been observed. In some ciises internal organs are affected, either 
during the attacks of local asphyxia or alternately with them. Thus 
transient hemiplegia has been recorded, and paroxysmal attacks of 
hjemoglobinuria (7. r.). The general symptoms which accompany 
the attacks are not characteristic. There is no fever, but the patient 
feels depressed, has no apj>etite, and occasionally suffers from delu- 
sions. Children who have Raynaud's disease are generally ill-nour- 
ished and rather dull, especially during cold weather. 

The treatment must consist mainly in warding off the attacks In- 
avoiding exposure to cold, and by keeping the patient warmly 
dressed. During the attacks the affected parts should be wrapped 
in cotton-wool ; in severe attacks the child should be kept in bed, 
and in the most severe it may be necessary to give morphia to re- 
lieve the pain. Moebius has suggested that a course of treatment 
by thyroid gland might be of use ; massage benefits some patients. 
Barlow advises the use of a galvanic bath for the limbs, one electrode 
being over the spine and the other in the water, which should con- 
tain some common salt. 

Prurigo is a chronic papular eru])tion attended by the most in- 
• Hr-c itcliing. It l)egins usually during the first year of life, when 
it is practically indistinguishalde from the much more common urti- 
caria papulosa. The papules, which are very persistent, are event- 
ually attende<l by a fibrous degeneration of the cutis due to long- 
lasting chronic inflammation. The papules occur in greatest number 
n the extensor surfiices of the limbs, esjx?cially of the legs, and 

usiderable glandular enlargement may ensue. Owing to the itch- 
ing the patients scratch violently, and various im])('tigin(»us lesions 
are usually to be found mixeil up with the papules and obscuring the 
iture of the affection. The disease is very obstinate, but is liable 



508 DISEASES OF THE SKIK 

to remissions and can be relieved by treatment, which should be of 
the same kind as that recommended for urticaria papulosa. The 
patients suifer a good deal in general health and nutrition, and need 
a nutritious diet, cod-liver oil, and preparations of iron. 

Urticaria pigmentosa is a rare aifection, allied to urticaria papu- 
losa, but differing in the character and distribution of the lesions 
and in its course. During the first few weeks, or, at latest, within 
three months of birth, urticarial patches of varying size, but reach- 
ing sometimes the diameter of half an inch, appear. They are at 
first conical and red, but after some days become flattened and of a 
brown color. Others appear in succession and pass through the 
same phases. The distribution is usually symmetrical, the parts 
chiefly aflected being the front and axillary areas of the thorax, the 
limbs, and the belly. Owing to the intense itching which attends 
the patches, various inflammatory lesions of the impetiginous type 
are apt to be produced by scratching. During the second year the 
spread of the disease becomes arrested, after the age of five or six 
years improvement begins, and recovery is generally complete in two 
or three years more. No treatment appears to be able to check the 
course of the disease, and all that can be done is to attend to the 
general health and nutrition, to relieve itching, and to treat compli- 
cating impetigo by the ordinary methods. 

Erythema signifies, properly, redness of the skin due to hypergemia 
of its more superficial parts, but the term has been extended to em- 
brace a number of other conditions in which hypersemia is an early 
or prominent symptom. 

Erythema simplex (patches of redness, seen usually on the face, or 
on the folds of the neck, axilla, groins, or buttocks) is extremely com- 
mon in infants and young children. The part is at first bright scar- 
let and hot, and there are sensations of burning and itching. The 
color fades to pink, and some slight desquamation and very super- 
ficial yellowish staining of the skin may attend subsidence of the 
erythema. In some cases it appears to be due to reflex irritation 
from difficult dentition, intestinal worms, or gastro-intestinal irrita- 
tion. In such cases it is usually fugitive, lasting perhaps only a few 
hours, but very apt to reappear either in the same or some other 
situation ; the term erythema fugax is applied to such cases. The 
erythema produced by exposure to the sun, or to the direct influence 
of cold winds, belongs to this class. 

Erythema involving folds of skin in contact with each other, 
erythema intertrigo, is a more obstinate aflection, and, owing doubt- 
less to the retention between the opposed surfaces of irritating 
secretions, is very apt to be complicated by true superficial inflam- 
mation, attended by weeping, which is absent in simple intertrigo. 
It sometimes extends over the abdomen, involving all the parts 



ERYTHEMA. 509 

covered by the napkin, aiul may thon raise a suspicion of congenital 
syphilis. The fact that in sypiiilis tiie erythema is more widespread, 
extending^ down tiie posterior aspect of the Iciis anil to the soles of the 
feet, and that the skin is usually a little thickened and has a brownish 
or purplish tint, taken together with a consideration of all the cir- 
cumstances of the case, will usually prevent error. It is, however, 
necessary to be on one's guard, and in cases of ol)stinate ervthema of 
the Inittocks to make careful searcii for other evidence of sypiiilis, 
which will seldom be altogether wanting. 

In the treatment of ervthema simplex the main indication is to dis- 
cover and remove the cause. The jiart should be dusted, or dabbed 
with calamine lotion. If the erythema l)e limited to the area covered 
by the napkin, it is probable that the napkins are not sufficiently 
washed, or that some irritating material is used by the laundress and 
not rinsed out, or that the napkin is not changed often euough. 
Intertrigo should always receive prompt attention. The parts should 
be kept scrupulously clean, using a weak boric acid solution, and avoid- 
ing soap as much as j>ossible, and well powdered, and should be kept 
apart by pledgets of absorbent cotton. [Dusting powder — zinc 
oxide, boric acid, starch powder — equal parts.] A muslin ])owder 
l)ag is a convenient application, l)Ut is not well suited for the buttocks 
and groins in infants, as it is very apt to become soiled. 

Erythema scarlatiniforme is the term applied to the erythematous 
luption which accom]xinies certain simple febrile affections, especially 
that form of pharyngitis or tonsillitis which is produced by ex]>osure 
to the emanations from foul drains. In other cases the rash occurs 
in the course of pneumonia, diphtheria, or septicjemia. It has been 
observed also as a complication of rheumatism, malaria, and syphilis, 
and has then been attributed by some to the toxic action of mercury, 
sodium salicylate, or other drug which has been aiUninistered. In a 
minority of cases no cause can be discovered, and in some individuals 
the disease shows a tendency to recur every spring, or at irregular 
intervals. Erythema of this character occasionally follows the ad- 
ministration of an enema. Not infrecpiently the erythema is nmre 
patchy, and a little resembles the eruption of uieasles (rubeoloid 
erythema). This tyj)e of erythema is due probably to the al>sorption 
i" toxic bodies from the intestines, and ervthema scarlatiniforme is 
robably, in all cases, a manifestation of a toxremic couditinn. IWaf- 
" nt therefore must be directed to the condition of the throat should 
it be inflamed, or of the stomach and intestines. It should be com- 
menced by the administration of a laxative dose of calomel, unless 
special conditions exist eontraindicating the use of the drug, when 
its place may Ix* taken by castor oil. The sauitary condition of the 
house should be inquired into, especially in those cases in which re- 
lapses occur. Even when no very marked gastro-intestinal symp- 



510 DISEASES OF THE SKIN. 

toms exist, regulation of the diet and the use of stomachics and in- 
testinal antiseptics should be resorted to. 

Erythema multiforme is an inflammatory disease of the skin only 
occasionally seen in children, and, in them at least, nearly always a 
manifestation of the rheumatic state. Its onset is attended by marked 
constitutional symptoms, fever, pains in the joints, sore throat, and 
diarrhoea. The rash, which is attended by some pain and burning, 
but not by much itching, appears as a rule first on the dorsal aspect 
of the hands and feet, and is distributed more or less symmetrically. 
Subsequently it extends to the forearm, thighs, and trunk, cover- 
ing sometimes very large areas. Beginning as an erythema, nearly 
every form of lesion of the skin — papules, vesicles, bullae, petechise 
may subsequently develop. On the whole the affection of the skin 
in any area tends to heal first at the points at which it appears first, 
so that concentric circles and intersecting rings of eruption after a 
time encircle, or surround in an irregular manner, patches of healthy 
skin. The duration is very uncertain ; an attack lasts usually sev- 
eral weeks, but as relapses are common the course of any case may 
be very much more prolonged. In rare cases the general symptoms 
are very severe, and the occurrence of pericarditis or endocarditis 
practically carries the case into a different category. Endocarditis 
is often of the malignant (infective) type, and the prognosis corre- 
spondingly serious. Treatment has not much effect on the course of 
the disease even in its milder forms. Sodium salicylate should be 
given at the onset for a day or two ; later quinine should be given, 
and small doses of opium may be required. After the disease has 
ceased to extend rapidly, arsenic is useful. Locally, calamine lotion 
or compresses wrung out of a weak carbolic lotion may be used to 
relieve the discomfort. The general management of convalescence 
should be the same as after rheumatic fever. 

Purpura, extravasation of blood into the superficial parts of the 
skin, as indicated by purple spots, streaks (vibices), and patches — 
small (petechise) or large (ecchymoses) — may be the result of any 
condition causing intense hypersemia of the skin, and is thus occasion- 
ally a consequence of erythema. In practice among the poorer 
classes the commonest cause of petechise is flea-bite. Marasmic in- 
fants and young children may often be seen covered with petechise, 
most abundant about the shoulders and chest, due to this cause. 
With a lens the central puncture may usually be made out. 

Peliosis rheumatica is an acute disorder characterized by purpura 
and joint pains. It occurs usually in patients who have already suf- 
fered from various rheumatic manifestations. It is not common in 
childhood. The onset is marked by general malaise, which is accom- 
panied by a rise of temperature. The joints then become painful, 
red, and swollen, and in a day or two the rash appears about the 



CHILBLAIN. 511 

wrists, knees, and ankles. It consists of red patches, which may W 
slightly raised, and do not fade on pressnre ; their color doei>cns 
quickly and finally becomes dark purple or black. As the rash 
comes out the joint pains abate, and the patient is convalescent in a 
few days unless the heart Ix^ involved, as is sometimes tlie case, or 
unless the rash occurs as a complication of distinct rheumatic fever. 
Even in the sligiitest cases, however, a relapse is very likely to occur 
after a week or two, and in some cases many such relapses succeed 
each other, so that the whole illness lasts several months. The pa- 
tient should be kept in Ixxl during the onset of the disease, and at 
each relapse. Sodium salicylate produces the same kind ()f allevia- 
tion as in other rheumatic atfectious. During couvalescence the pa- 
tient should have a nourishing diet and as much fresh fruit as can be 
taken without inconvenience. Iron preparations are also to be re- 
commended, as a rule. 

Chilblain, to which the term cri/thcma pernio has Ix'cn applied, 
not very happily, is in reality an acute inflammation of the whole 
substance of the skin. It is a very common affection in children, 
especially those who are growing fast, and are " big for their age." 
It runs in families, and is |>erhaps most common in neurotic children 
and in those of '* scrofulous " type. It affects chiefly the hands, 
feet, and ears, parts which are exposed and are farthest removed 
from the centre of the circulation. When the circulation is poor, as, 
for instance, in a paralyzed limb, the liability to chill)lain is greater, 
and large tracts of skin may be involved. The disease comes on 
usually during weather which is both cold and damp. A child who 
has been almost free during a hard frost will begin to suffer severely 
during the succeeding thaw. Once established, the liability to re- 
lapse is very marked ; recurrence is also the rule, so that the }>atient 
suffers during each succeeding winter, from early childhood until 
adult age. Chilblain is an extremely distressing disorder, owing to 
the intense itching and aching wliich attends the acute stage. If 
neglecteil at this stage a Idain, or large shallow bleb, forms. This 
is easily ruptured by scratching or by friction of the clothes, and we 
then have a condition in which a shallow but very vascular ulcer 
rests upon and is surrounde^l by skin in a condition of acute inflam- 
mation. The part in this stage is extremely tender, and the child 
dreads even a light touch, so that it avoids games and desires to kee]> 
still. Severe chilblain on the feet, in fact, render walking practically 
impossible. Occasionally beneath the blain, or even before it has 
formed, necrosis occurs, and a deep ulcer with sharply cut edges re- 
sults. This has no sj>ecial characters and is not exquisitely tender, 
as is th<' ff»rni do-rrilK «] al)r>ve. 

The prophylactic treatment of chilblains is a matter of considerable 
impf>rtance, since when once develojKjd they are extremely obstinate, 



512 DISEASES OF THE SKIN. 

and if severe, prevent the child taking exercise, joining in school 
games, and by the constant irritation and interference with sleep pro- 
dnce a condition of great nervous irritability and a general deterio- 
ration of the health. The most important precaution is to see that 
the child does not wear damp clothes. During a thaw and at other 
times when the air is near saturation point, all clothes, but especially 
Avoollen garments, and boots and shoes, readily take up a large 
quantity of water. The use of such garments, but especially damp 
gloves and boots, keeps the parts constantly cold, and undoubtedly 
favors the production of chilblains. If the child is old enough it 
should wear woollen vests and drawers, knitted woollen armlets and 
stockings, thick-soled shoes (not boots) and cloth gaiters. Every 
garment should be well aired ; gloves, stockings and boots should be 
taken off as soon as the child comes in and replaced by aired gar- 
ments. If the cold morning bath is given — and it should be replaced 
by a hot bath if reaction is not good, or if the child shows dread of 
cold water — it should be followed by vigorous rubbing with a floc- 
culent towel in a warm room. The child should be taken out of 
doors as much as possible, but should be made to take exercise and 
not allowed to dawdle about. The diet should be plain and ample, 
containing a full proportion of proteids. As a rule, alcoholic bev- 
erages should not be allowed. 

The treatment when once the chilblain has formed must depend 
upon its stage. In the earliest erythematous stage the greatest relief 
is obtained by plunging the part into hot water, and gradually rais- 
ing the temperature by adding hotter water. After such a bath of 
ten or fifteen minutes' duration, the congestion is very much dimin- 
ished. The part should then be thoroughly dried with a soft towel, 
smeared with belladonna and glycerine, and packed with absorbent 
cotton-wool, retained in place by a bandage applied firmly. This 
should be done the last thing at night and twice or thrice during the 
day. If the chilblains are small they may be painted with tincture 
of iodine, which has a gently astringent action. Itching is relieved 
by compound tincture of benzoin and by camphorated spirits, but 
best by a cocaine ointment. The application of collodion with the 
idea of exerting pressure on the chilblain is usually worse than use- 
less. The collodion cracks with the movement of the part, and in 
each crack a shallow linear ulcer forms. A somewhat similar objec- 
tion applies to iodine if used in too strong a solution. When a bleb 
has formed it should be dressed with a simple antiseptic ointment of 
boric acid to which a little cocaine is added, or of carbolic acid, and 
should be protected from injury. The painful vascular ulcer should 
be treated with an antiseptic ointment and continuous hot fomenta- 
tions or poultices. It is absolutely necessary to give the part rest, 
and if the feet be the part affected, the child must be kept in bed or 



I 



CHILBLAIN. 513 

oil the sofa for a day or two. When onee the surrounding dermatitis 
has subsided the shallow ulcer will heal quiekly. Uloer succeeding 
sphacelus must be treated on ordinary surgical principles. Internal 
remedies have little or no etfect, except, perhaps, preparations of 
iron, especially the perchloride when it can be borne. If not, the 
syrup of the phosphate may be given. Cod-liver oil should not be 
given unless other indications exist for its use. 

Pemphigus is a term often used very kK)sely ; it should be contiiied 
to those cases in which, with or without slight antecedent erythema 
of the area to be affected, a bulla appears, rapidly attains its full 
size, and in the course of a day or two dries up, leaving a dark vel- 
lowish scab, under which the skin, covered by delicate epithelium, 
has a bluish color. The color changes to brown, and no scarring 
results. The mucous membranes are attacked occasionally. The 
etiology of pemphigus is obscure. In some cases an hereditary ten- 
dency exists. In othei*s, the disease apparently has a septic origin, 
and the lesions are probably due to toxtemia (see " Pemphigus Neona- 
torum "). The bullae appear at first in crops on various jxirts of the 
limbs, trunk, and face (lower part), and there is fever and some 
general disturbance of the health. Occasionally haMiiorrhage takes 
place into the bullae. More often, owing to scratching and want of 
attention, suppuration occurs, usually after rupture of the bleb, and 
ulceration ensues. In feeble children the presence of numerous 
bullse, especially if suppuration ensue in connection with them, pro- 
duces great exhaustion. Independently of discoverable infection, 
the intensity of the local lesion may cause gangrene and sloughing. 
Except in cases of this type, recovery after a few weeks is the rule, 
though there is considerable liability to relapse and recurrence. 

Though usually chronic or subacute, pemphigus is occasionally, 
especially in young children, very acute (malignant). The number 
of bullae is very large, and appear in rapid succession. Fever does 
not disappear soon after the onset, as is the rule, but is continuous, 
and the jxitient^s strength is rapidly exhausted, and death occurs in 
a week or two. 

The diagnosis is not always easy unless the case can be watched or 
a thoroughly trustworthy history oV>tained. True pemphigus is, in 
my experience, a rare affection in childh(X)d. The great majority of 
the cases to which the term is commonly ajiplied are examples of 
pyococcal infection in w^hich the inflammation spreads with great 
rapidity immediately beneath the epidermis and thus produces large 
blebs, which rupture or dry up before obvious suppuration occurs. 

In the treatment of true pemphigus the main indication is the 
administration of arsenic. A small dose should l>e given at first, 
and increased more or less rapidly according to circumstances. (Qui- 
nine is also a valuable remedy, and should be given at the same time. 
33 



514 DISEASES OF THE SKIN, 

Failing arsenic, phosphorus or belladonna should be tried. Locally, 
the condition should be treated by antiseptic ointments, and the blebs 
should be guarded from rupture. If very tense, they must be punc- 
tured with a sterilized needle, and dressed with a mild antiseptic 
ointment. The general strength should be maintained by placing the 
patient under the best obtainable hygienic conditions, taking him into 
the open air when possible, and administering a copious simple diet. 

Herpes is the term applied to a vesicular eruption which occurs 
under two very different conditions, though in both the arrangement 
of the vesicles appears to be governed by the distribution of the 
nerves of the part. The characteristic lesion is a cluster of small 
vesicles, which form upon a limited area which has for some short 
time previously been hot, swollen, tense, and painful. The contents 
of the vesicles become opaque, often purulent, and eventually a yel- 
lowish scab forms, which finally is detached without in most instances 
leaving any scar. 

Symptomatic herpes is exceedingly common in infancy and child- 
hood. It occurs usually as a complication of coryza, or pneumonia, 
and runs through its several stages rapidly, though not infrequently 
it is succeeded* by local impetigo. It affects usually the lip (herpes 
labialis), most often near the middle line. Very rarely in children 
does it occur on the genitals. The only treatment required for the 
local condition is the application of a mild antiseptic ointment. 

Herpes zoster is exceedingly rare in young children. As the age 
of puberty is approached it becomes far from uncommon. Its causes, 
symptoms, and course in children do not differ from those of the 
same condition in the adult. 

Pruritus — that is to say, reflex itching, without discoverable local 
cause to account for it — is extremely rare in childhood, except at 
the nasal and anal orifices, and in the external auditory meatus. 
Pruritus ani or vulvae is usually due to intestinal parasites, to haemor- 
rhoids or polypus of the rectum, or to retained masses of hardened 
faeces, and cases when the rectum and large intestine have been 
treated effectually. Itching of the nose, which causes the child to 
be constantly picking and scratching at it, appears to be associated 
with irritation somewhat higher up the intestine, and is especially 
common in children infested by ascaris lumbricoides. It is, however, 
sometimes due to chronic rhinitis and naso-pharyngitis. Pruritus of 
the ear is usually a symptom of middle-ear disease (see " Otitis ^^), 
sometimes of naso-pharyngitis. 

Itching is a symptom common to many forms of skin disease, and 
owing to the irresistible desire to scratch, it is the indirect cause of 
complications by inflammation due to pus-forming micro-organisms. 
Itching of the head should raise the suspicion of pediculosis, of the 
body generally of lice, fleas, or bugs ; of the hands and feet, of scabies. 



SCABIES. 515 

The first step in treatment is to reiuovo the cause. \\'lion pediculi 
capitis are present, thev will be found in laro;est nunihers in the oc- 
cipital region. They must not be assunied to be absent because the 
patient has clean clothes and is well cared for. The hair should be 
cut as short as the parents will allow : if inijietigo be present the 
euttinjr of the hair should be insistetl on. The hair shmdd be 
washed with hot water and a little soft soap, or with soa]> s|;irit, and 
combed out, — after it has dried it should be wetted with acetic acid 
lotion, which has a solvent action on the glutinous matter by which 
the nits are fixed to the hairs. Subsetpiently a mild sulphur oint- 
ment should be used as a pomade. AVhen the number of nits is not 
very large, this ointment, combined with daily combing, will be suf- 
ficient. A lotion which has long been jwpular at the Shadwell 
Children's Hospital contains mercury perch loride, acetic acid, turpen- 
tine, and carbolic acid. 

[Lotio Hydrarjjyri o. Aoido Carbolico (Shadwell) — 

Liq. Hydra TiT. Perchlor., n\^xx 

Ac-idi Acetioi Dil., rr^xl 

Ol. Terehinthinjv, O'J 

Sol. ac, Carbol. (1 in 40), ad .^j. Appendix.] 

It is an example of poly-pharmacy, but it is very useful with dirty 
people who will not take much trouble. Body lice are, for some 
reason (possibly because their clothes are more often changed and 
washed), rare in infants and not very common in children, even 
among the jworest classes. 

Scabies is probal)ly neither more nor less common in children 
than in adults. In infants it is sometimes met with on the head and 
face, but its seat of predilection is on the webs between the fingers 
and toes. With these exceptions it presents no peculiarities in early 
life. An eruption, most marked on the fingers, the back (»f the 
hands, the toes and the dorsum of the foot, should raise a suspicion 
f scabies. It should l>e remembered that the itching j)roduced may 
A tend far Ixn-ond the actual seat of the primary lesif»n. Supj)u ra- 
tion quicklv ensues in and about the burrows in children who arc 
not very clean, and the purulent infection is rapidly carried l)y the 
finger nails to distant parts, the seat of reflex itching. The front 
of the trunk, the back, and indeed, every part of the ])erson, may 
thus become crivered with suppurative lesions in various stages. 

In the treatment of i^cabies in children the rjrdinary method 
h«>uld not be too vigorously applied, as it is easy to stir up an ex- 

-sive amount of general irritation of the skin. As a rule, treat- 
ment may be commenced by giving a warm bath with soft soap, 
which removes the superficial dermatitis and lays bare the burrows, 
^ulphur ointment (precipitated sulphur, gr. xx-xxx to ."^j of lard or 



516 DISEASES OF THE SKIK 

equal parts of lard and vaseline, with a little essence of lemon to 
cover the odor) should then be rubbed in, at first four times a 
dav, afterwards once a day. If the infection be confined to the 
hands or feet, and accompanied by much crusting from suppurating 
lesions, the parts should be first soaked in carbolic oil for a day or 
two, after which the washing and sulphur treatment may be com- 
menced. In the same way, when extensive impetiginous lesions 
are present in many parts of the body, treatment should be com- 
menced by a mild sulphur and zinc ointment, and when the impetigo 
and other suppurative lesions have begun to subside, the special 
treatment may be commenced. The clothes should be stoved or 
boiled. 

For the relief of itching, of which the cause cannot at once be re- 
moved or discovered, various local sedatives and anaesthetics may be 
used. A warm bran, starch, or alkaline bath is often very soothing, 
as is also a hot bath with a non-irritating soap. Lint steeped in 
vinegar and water (equal parts), or in a simple spirit evaporating 
lotion, and applied to the part where the itching is most intense, 
gives temporary relief. A saturated solution of menthol in spirit 
painted on produces a grateful sense of coolness. Carbolic acid, or 
menthol, or cocaine in a lanoline ointment base, has a more lasting 
effect, and the first named will sometimes have a curative effect by 
removing the cause. Occasionally salicylic acid (gr. x to gj) has 
a good effect for the same reason. 



CH APTKl^v X T.VIT. 
DISEASES OF THE SKI'S— {contimiedy 

Py(K*(Hval iVrmatitis — Iinj»otiiro — Catarrhal I Vnnatitis — Funuulo — Ixinirworm — 
AlojHX-ia Areata — Seborrho^a — LicluMi — Miliaria — Ko/«.ina and Psoriasis. 

Dermatitis due to infection by pus-forming organisms, owing 
to the tVeqiRncy with whicli it occurs, ovcrsha(h)ws in practical im- 
portance all other forms of skin disease in ciiildhood. Xot oidy 
does it occur as a [priniarv atfection, hut it is very liable to comj>li- 
cate almost every other form of skin disease, especially amontr those 
classes of the people who are disposed to neglect the earlier manifes- 
tations of disease, and by whom cleanliness is little regarded. The 
infective agent is, as a rule, one of the pyogenic staphylococci 
(aureus, citreus, or albus), but sometimes the pyogenic streptococcus. 
The lesions produced by the latter are, as a rule, more severe and 
more dis{>osed to spread by contiguity. 

Three main varieties may be distinguished : impetigo, catarrhal 
<lermatitis, and furuncle. Pyogenic organisms are usually present 
in various parts of the skin in health, and the opportunity toclevelop 
and to prrMluce their characteristic lesions is afforded usually by 
traumatism or irritation, more rarely by some deterioration of tiie 
general health, which has diminislied the resistance of the skin. 

Impetigo is a pustular erui)tion which may attack any part of the 
'irface, but is especially frequent on the exposed parts. The or- 
_.inisms present are usually staphylococci. The su])])uration may 
..' preceded by a l)nef vesicular stage. It may be determined by 
almost any s<^>urce of irritation. Thus on the scalp it fn^juently 
♦^•omplicates pe<liculosis ; on the face it is often derived from the 
vesicles of herpes labialis which have become infected ; on the hands 
and feet it is prone to follow any accidental scratch or abrasion which 
has not been kept clean ; or it is secondary to scal)ies, or contracted 
by scratching some other part already infected. Self-inoculation is, 
Ml fact, one of its most striking characters. The infection may be 

irried not only by the finger nails but also by the clothing. Thus 

is not uncommon to see a patch of imix-tiginous dermatitis well 
icvelojx'd on the outer side of the malleolus on one side, and in an 

irlier stage on the inner mallef)lus on the other side, the infection 
iiaving clearly been carried by the interchange of <tf>ckings. The 

517 



518 DISEASES OF THE SKIN. 

list of such occurrences might be multiplied almost indefinitely. 
The infection may, under certain favoring circumstances, among 
which perhaps the degree of virulence of the staphylococcus is one, 
be contracted from a previous case, whence the term impetigo con- 
tagiosa. Occasionally widespread impetigo will be found to have 
had its origin in a mild attack of varicella for which medical advice 
has not been sought. The pustules rupture and the surface becomes 
covered with crusts, which are at first easily detached, but subse- 
quently become more firmly adherent. Beneath the scabs suppura- 
tion may occur. 

There is a variety, due in many if not in all cases to the strepto- 
coccus, in which the inflammatory process spreads with great ra- 
pidity immediately beneath the epidermis ; the fluid effused, which 
is at first serous or opalescent, raises the epidermis, forming some- 
times more or less circular bullae, more often irregular flattened shal- 
low cavities, which tend to spread rapidly. In many cases the scar 
of the scratch by which the infection has been introduced can easily 
be detected. This form of creeping dermatitis occurs especially on 
the fingers. When the suppuration takes place under dense epi- 
dermis, as on the palmar surface of the fingers or thumb, the process 
causes a good deal of pain, and may be mistaken for deep-seated 
whitlow. 

Catarrhal dermatitis, due to pus-forming organisms, may occur 
on any part of the body, but is specially frequent on the face and in 
the folds of the skin. It is often a sequel to impetigo, and near the 
margin a few pustules may almost invariably be found. On the face 
it is secondary to herpes, to stomatitis, or to suppurative rhinitis. 
Its most characteristic form is seen as a consequence of the last-named 
disorder. The secretions from the nose traversing the upper lip may 
produce a copious crop of impetigo, a crusting dermatitis, or a superA I 
ficial dermatitis, which, if neglected, soon begins to ulcerate. A~^ 
more widespread and usually less severe dermatitis is produced if in 
wiping the nose (often in boys of the poorer classes with the back of 
the hand) the purulent secretion is rubbed into the upper lip and the 
cheeks. The skin becomes red, then glazed, it cracks and begins to 
weep, leading to the formation of thin yellow crusts with, probably, 
some scattered impetigo at the 'margins of the lesion. In the folds 
of the skin, behind the ear, in the buttocks and groins, and, in in- 
fants, among the rolls of skin in the neck and at the ankles and 
knees, an inflammatory intertrigo is easily produced. The sides of 
the fold are red, dry, often desquamating, while at the bottom there 
is a collection of pustules or a shallow linear ulcer. Under un- 
favorable conditions of personal and domestic hygiene this ulceration 
may extend rapidly, causing considerable loss of substance and even 
placing the infant's life in danger. 






I 



RING WORM. 519 

In the treatment of impetigo the main }K)ints are to (1) provont 
the extension of the disease bv seratchino- or hv wearinir (v^ntaniinated 
garments, ['2) to remove erusts bv soaking in oil (earbolized), and (^.'>) 
to apply some parasiticide, of which sulphnr is perhaps the best, 
though white precipitate and other mercurial preparations answer 
very well. The remedies are best used in ointment, and if then^ be 
much irritation of the skin, the sulphur ointment should be freely 
diluted and moditied by the addition of zinc oxide. Salicylic acid 
ointment (gr. x-xv to 5j) made with vaseline, or with lanoline and 
olive oil, is a valuable remedy, especially for impetigo about the face. 
A very useful ointment when there is much irritation consists of 
salicylic acid (gr. xv), bismuth carbonate and starch powder (of each 
3j), in zinc ointment (oj). Superticial catarrhal dermatitis should be 
treated in the same way. In intertrigo the parts must be kept very 
clean by the use of antiseptics in oil or ointment, well dusted with an 
antiseptic powder — [Antiseptic dusting |Hnvder : zinc oxide, boric 
acid, starch jx>wder, mercury subchloride, equal parts] — and the 
folds kept apart by pledgets of absorl)ent cotton or boracic lint dusted 
with mild lx)ric acid powder. Ulceration should be treated with 
mercury perchloride solution (1 in 2,(M)0), or with black wash, or l)y 
the careful application of calomel in powder, followed by the syste- 
matic use of a dusting powder containing about one-fourth calomel. 
Creeping suppuration l>eneath the cuticle must be treated by sni])j)ing 
away the detached epidermis and apjilying calomel or ioch^form in 
powder, taking care that the powder reaches the spreading edge. 
This should be followed by the use of antiseptic ointments. 

Furuncle, a localized inflammation of the substance of the skin, 
due to staphylococci, and originating in a follicle, or in a sweat or 
sebaceous gland, is probably less common in children, especially in 
young children, than in adults. When boils occur they do not diifer 
in any respect from those seen in adults, and are produced by like 
causes. Simple furuncle must be distinguished from the condition 

died syphilitic furuncle (rj. v.). 
RingworiQ is due to infection of the hair follicles and hairs by 

ne of the species of trichophyton. Two chief sjwcies have been dis- 
linguished by Sabouraud. They differ in their mode of growth on 
artificial media, and in the part of the l)ody which is their seat of 

Ir-ction. (1) Trlr/iojfhjfton microHporon, which is the cinise of the 

lajority (two-thirdsj of the cases of tinea capitis, has small spores 
and a very scantv mycelium. When it infects the hairs as well as 

he root-sheath it is verj' inveterate. Ill-defined varieties are de- 

ribe<l, but the species is almost confined to man. (2) Trirhophj/ton 

'7a/o^y>o/-o/j, which is found in most cases of ringworm of the body, 

;uLS large spores and a relatively copious mycelium. Sevend varieties 

are described which infect raanv animals as well as man. 



520 DISEASES OF THE SKIN. 

Trichophyton is itself capable of exciting a certain amount of in- 
flammatory reaction, but this specific inflammation readily becomes 
complicated, since it aifords conditions very suitable to the develop- 
ment of pyococci. The inflammation provoked by trichophyton in 
the root-sheath, when it has persisted for some time, is succeeded by 
a fibrous thickening which tends to occlude the orifice of the follicle, 
while the fungus continues to grow in its deeper part. This is one 
of the main causes of the inveterate character of tinea capitis Avhen 
well established, for the constriction of the orifice renders it difficult 
so to apply remedies that they reach the bottom of the follicle, 
where the infective agent is most active. 

Ringworm of the scalp, though a disease seldom observed after 
the age of childhood, is discussed so fully in works on skin diseases 
and on general medicine that it need not be dealt with here at length. 
It appears first as a small red spot having a hair follicle for its centre ; 
the spot enlarges and forms a round red patch, slightly elevated. In 
the next stage the redness fades ; several areas have probably run 
together, and we have a dry surface covered with a fine scurf and 
showing, either over all its area or in greater number near its mar- 
gin, numerous clubbed and broken hairs, which are easily pulled out. 
In a stage still later the areas are less well defined, indeed almost the 
whole scalp may be afl^ected. The hair is scanty, and the individual 
hairs are thin, dry, and brittle, but the characteristic broken stumps 
of the original hairs will probably all have disappeared. 

Ringworm of the body begins in the same way — as a small red 
spot which spreads rapidly. The spreading edge is red and raised, 
while the centre ceases to be raised and becomes covered with a fine 
desquamation (tinea circinata). In some cases the inflammation does 
not subside so rapidly in the centre, and then red raised patches are 
produced. The favorite seats of ringworm of the body are the neck, 
face, wrists, back of the hands, and the outer surfaces of the lower 
extremities. 

Kerion is the term applied to ringworm complicated by suppura- 
tion in the deeper parts of the skin. The suppuration begins at the 
bottom of the follicles, the skin is undermined and gives to the finger 
a boggy sensation. The pus finds its way out by the follicles Avhich 
are destroyed, the hairs being extruded, so that when the suppura- 
tion subsides the ringworm also is usually cured. 

In ringworm of the body and in ringworm of the scalp in the early 
stage treatment effectually applied will rapidly cut short the disease. 
The patch should be treated with iodine liniment, or blistering fluid, or 
acetic acid, which remove the superficial epidermis. Parasiticide rem- 
edies should then be applied. Of these the best are ointments of 
chrysarobin, salicylic acid, or a combination of the two (see Appen- 
dix), mercurials (of which oleate of mercury is the best), or sulphur. 



ALOPECIA AREATA. 621 

[Ung. Chrysirobin Co. (Unna). 

C"hrvs;\r(»bine, 5 parts. 

Saluvlie Acid. 2 ** 

Ichtlivol, 5 " 

Simple Ointnu'iu. ]()(» " ] 

Whatever ointment be selected, it should be rubbed in thoroughly 
thrice a day, using a small quantity on each occasion. In ringworm 
of the scalp tliis treatment must be preceded by epilation, and it is a 
great advantage to have the head shaved, so that small connucncing 
areas may be seen and treated. If, as is too often the case, this 
treatment fail to arrest tinea capitis, an attempt should next l)e made 
to eradicate the disease by the use of spirit lotions containing some 
germicide, of which salicylic acid is prol)ably tlic best. 

In the majority of cases, however, the disease has already, when 
the case first comes under treatment, reached a stage when all local 
inflammatory reaction has ceased. The head should be washed with 
soft soap and water or spirit (^f soft soap (spir. saponis kalini), to re- 
move scurf, scales, and dead hairs, and then shaved. [Sjiirit of soft 
soap (spiritus saponis kalini), — half a pound of soft soap is mixed 
thoroughly with 4 fl. oz. of rectified spirit strained through muslin, 
and scentetl with oil of lavender (o drops).] The number of j)ara- 
sitieides recommended and used witli more or less success is legion. 
Among these chrysarolnn ointment (about .jj to .\j) is probably tlie 
best, but sul})hur, white precipitate, oleate of mercury (commencing 
with 5 per cent.), and oleate of copper are useful. The mode of 
application is tlie main point. To smear the head once a day with 
ointment is useless. The hair must be short, the scalp clean, and 
the ointment must not only be well rubbed in but a cap fitted so that 
it is not rubbed off.' 

The prevenf ion of ringworm of the scalp is an important ]>art of 
-' hool hygiene. The infection is spread from one family to auotiier 
mainly In' the intimate contact which takes ])lace in class, at meals, 
and during games. The most effectual mode of checking tiie spread 
is to put children affected with tinea capitis in aschcK)! by themselves. 
In Rome I saw a central school, established in an old monastery with 
a large garden. The children were treated and taught in this estab- 
lishment until well. Failing such a special school, children with 
ringworm should be taught in a separate class-room, and have a 
>'parate playground. 

Alopecia areata — crmiplete loss of hair in certain areas — may be 
dne(l; to nervous shock, a very rare event; (2) to infection by 
trichophyton ; or (3) to iDfection by a special microbe, apparently a 

' A poofl cap, which co«t«« little ami fitw closely, may In* made with a y'u-ir of 
tranze placed civer the head, retained hy a few tunis of tfanzc handa^rr and cnnsfdi- 
datecl by painting with UnnaN gelatine, over which cotton-wcMil is dabln-d. 



522 DISEASES OF THE SKIN. 

small bacillus which infects the hair follicle, and grows into the hair, 
which becomes detached and falls out. 

The diagnosis of the two varieties last named, which are not un- 
common in childhood, is usually difficult ; in alopecia due to the 
ringworm fungus broken hairs may be discovered near the margin, 
and the characteristic spores may be found. This variety of ring- 
worm tends to recover spontaneously, and is therefore considered to 
be very amenable to treatment. In the third form there is little or 
no tendency to spontaneous recovery, but a cure may often be ob- 
tained by the systematic use of parasiticides, of which sulphur oint- 
ment is probably the best. Its strength should be gr. xx to Sj at 
first, but it should be increased unless the amount of irritation pro- 
duced is considerable. 

Seborrhoea is a disease in which there is an increased production 
of the fatty secretions of the skin with, as a rule, some persistent 
hypersemia. Seborrhoea is spoken of sometimes as though it were 
merely an excess of secretion, a functional disorder, but it is more 
than this. There can be little doubt that the skin is the seat of 
some infective agent, though it is not often possible to find any 
probable source of infection, and among the very large number of 
micro-organisms present in the secretions in such cases no one has 
been identified as the cause. As the disease is very common, and 
as the infective agent must be very widely diffused, it is necessary to 
assume some special susceptibility of the skin in those persons who 
contract the disorder. 

The disease is of very great importance in practice, for even if 
we do not accept Unna's dictum that were the seborrhoea of chil- 
dren to be thoroughly treated eczema in adults would cease, it must 
be admitted that the disease can be treated effectually in children, 
and that if not so treated it gives rise to an exceedingly obstinate con- 
dition in the adult, which is either inveterate seborrhoea or, as others 
maintain, seborrhoea complicated by eczema. 

Seborrhoea is a local disease of the skin, and its subjects may be, 
and often are, otherwise in robust health. At the same time, de- 
bilitating diseases such as the acute fevers and diarrhoea produce a 
certain predisposition. 

Two varieties of seborrhoea may be distinguished : The dry, 
seborrhoea sicca, in which the fats with a high melting point pre- 
dominate, and the oily seborrhoea oleosa, in which the fats with a low 
melting point are in excess. The first named is the form by which 
the scalp is most often affected, and, perhaps for this reason, that 
usually seen in infancy. 

Seborrhoea always begins on the scalp, and when present elsewhere 
can be found almost always in that situation also. In a well-marked 
case of seborrhoea capitis in an infant the scalp is covered by a greasy. 



I SEBORRIKEA. 523 

dirty-yellow crust, which easily crumbles or scales aw:iy. The skin 
itself may be a little reddeued, or not much, if at ail, altered in color. 
The crust is thickest and most continuous over and aixtut tiie anterior 
fontanelle, owing probably to the absence of friction and to the very 

'oinmon disinclination to cleanse this part of the head. At a later 

ue there may be no more than a general greasy scurf of the hairy 
scalp, though down to the age of Hve or six, at least, crusts are very 
apt to form if the head does not receive systematic attention. The 
hair is scanty, lustreless, and brittle. 

The oily form is that which is seen most often on the face, and 
that which shows the greater readiness to spread, though it may l)e 
doubted whether there is any essential patiiological diiVercnce between 
the two forms. Indeeil, if I may hazard an opinion founded u|K)n 
the observation of a large number of Ciises, the oily form is, in children 
at least, due to a more active state of the infective process brought 
about by a greater activity of the }>hysi(^logical functions of the skin. 
On the face, trunk, and limbs the oily form pnxluces yellowish, 
greasy crusts formed of the dried secretion and of epitlielial sc^des 
resting on an area of hypenemic skin, which is often surrounded by 
scattered papules. The hypera^mia persists after the removal of the 
scales, which are readily reproduced. The appearances i)resent, 
therefore, a considerable resemblance to those of eczema. On the 
trunk and limbs the dry form produces hypera^mic i)atches covered 
by dry, whitish, or opalescent greasy scales, so that the condition 
may resemble psoriasis rather closely. The scales of psoriasis are 
drier, less greasy, more glistening, and tougher, but the diagnosis 
must rest mainly ujwn the discovery of seborrhcea of the scalp, or on 
a history that the scalp was the part first affected, as is always the 
case in seborrhcea. 

In extending from the scalp to the trunk scborrho^a usually fol- 
lows certain lines, which are those naturally taken under ordinary 
rcumstances by the sweat. This applies more particularly to 
icliorrhfea oleosa. Thus the patches may be observe<l to be older 
and more numerous at the back of the neck, and to extend in the 
vertebral groove to the waist, and at this level, where the expansion 
of the hips and the use of tight waistbands tend to arrest the sweat, 
a broad band of patches will often be found. The sweat descending 
on to the face from the scalp flows down the temples, or over the fore- 
head to the eyebrows, by which it is directed towards the temples 
and ears. Patches of seborrhrea are common al>out the temples and 
before and l)ehind the ear. Sweat descending over the forehead in 
tlie middle line escapes the eyebrows and flows down the sides 

: the nos<* into the naso-labial folds to the corners of the mouth. 

i he alse nasi, the naso-labial fr»Ids, the corners of the mouth, and 
the sides of the chin are the parts of the face most often aflfected. 



524 DISEASES OF THE SKIN. 

The recognition of this mode of distribution will often be useful in 
diagnosis. 

A seborrhoeic skin is very apt to become the seat of secondary in- 
fections by pyococci. Thus suppuration may occur under the crusts 
on the scalp, and the infection may be inoculated on to the hands, face, 
or trunk, producing patches of impetigo, or superficial weeping der- 
matitis. The secondary pyococcal infection may cause adenitis of the 
cervical glands, and when seborrhoea, suppuration, and pediculi capitis 
occur together the adenitis is usually severe and often ends in 
glandular abscesses. In other cases seborrhoea, it is said, becomes 
complicated with '^ true eczema.'' 

The diagnosis of dry seborrhcea of the scalp cannot present any 
difficulty, and there can seldom be any hesitation as to the oily form 
on the trunk since the distribution and character of the lesions are 
characteristic. The great similarity of the dry form on the trunk 
and limbs to psoriasis has already been mentioned, and the points 
upon which a diagnosis must be founded has been indicated. 

In the treatment the all-important point is the thorough and per- 
severing application to the skin itself of a suitable parasiticide. 
Special attention must in all cases be directed to the scalp. When 
it is covered by thick crusts these must first be removed. This may 
be done with hot water and soap, or soft soap spirit. The washing 
must be repeated at first daily, then as the seborrhoea improves, at 
longer intervals. In the neglected children of the poor the crusts 
are often very thick and matted together with the hair into an in- 
tractable carapace. Under such circumstances it may be necessary 
to begin by soaking with olive oil to which some paraffin (about one- 
third) has been added. If the hair be long it must be cut, and the 
clipping completed evenly after the crusts have been removed ; it 
should be kept quite short throughout the whole treatment. The 
parasiticide most generally useful is sulphur. To the scalp, when 
the hair is dry, it is best applied in ointment (gr. x to 3j, in- 
creased gradually), combined, if the skin be irritable, with zinc oxide. 
A powder in some cases, especially if there be much oily or serous 
secretion, suits better (5ss to Sj of fine talc powder with about gr. xv 
of borax), or the sulphur may be applied as a lotion (3j to water 3j, 
shaken before use), well rubbed into the scalp with a brush. In 
either case the precipitated sulphur forms a cake w^iich must subse- 
quently be removed. Salicylic acid is a useful addition both to 
ointments and poAvders, especially when secondary infections exist. 
As a substitute for sulphur, or in alternation with it, mercurial prep- 
arations may be used. Of these, white precipitate or yellow oxide 
(gr. v-x to oj) in ointment, with vaseline, or lanoline softened by 
the addition of olive oil, are, perhaps, the most convenient ; or per- 
chloride solution (1 in 2,000) maybe rubbed into the scalp. Naph- 



MALARIA OR SUDAMIXA. 525 

thol ointment, rendered almost fluid l>v the addit'uMi o{ oil. is also a 
good preparation. 

Lichen is a term verv loosely applied to pai)iilar eruptions, espe- 
cially in children. It is usually a cloak for ignorance and Malcolm 
Morris^ proposes to limit its use to lichen ruber planus, a disease 
resembling psoriasis, but due probably to a peculiar iuflauiuiation of 
the skin starting from the sweat glands. It is of such rare occur- 
rence in childhood that it need not be describeil here. Lichen 
strophnlosis is a form of miliaria not uncommon in infants. Lichen 
simplex and lichen agrius are stages of eczema, and lichen urticatus 
a form of urticaria (7. r.) common in children. 

Miliaria or sudamina are produced by obstruct ii^i of the sweat 
ducts ; the sweat unable to escajK? is eflused beneath the horny layer, 
producing a small vesicle. Sudamina are most apt to appear after 
the sweat function has been arrested for a time, as by fever. They 
are usually most numerous on the front of the chest and the abdo- 
men. They disappear in a few days, leaving no trace. Should 
inflammatory reaction take place about the sweat gland, owing to the 
retention of the secretion, a bright red ])apule is })roduced. The 
term miliaria rubra is applied to this condition, which is not uncom- 
mon in infants who are clad too warmly, especially if the material 
next the skin is irritating. This form of miliaria was formerly called 
strophulus, and is commonly known as ** red gum." Sometimes the 
papule is crowned l)y a vesicle or pustule, but as a rule these do not 
rupture, and each individual spot disappears in a few days. Atten- 
tion to the clothing and the use of an antiseptic dusting powder is, 
as a rule, all that is required. 

True eczema — that is to say, to quote Morris' definition, " a 
catarrhal inflammation of the skin originating with(^ut visible ex- 
ternal irritation, and characterized in some stage of its evolution by 
serous exudation " — is a rare affection in childhood. The vast ma- 
jority of cases commonly called eczema are, in infants and young 
children, examples either of selwrrhnea or of pyococcal infection 
(pyosis) of the skin. The disease when it occurs in children does 
not produce conditions differing in any resj>ect from those o!)served 
in adults. The same remark applies to psoriasis, which niay com- 
mence in early childhood. Lesions of the skin due to syphilis are 
considered in the chapter on that disease. 

>"Di^a>*esof the Skin," London, 1894. p. 13«>. 



APPENDIX. 



Absorption and excretion are both extremely rapid in infants and 
young children. It is, therefore, desirable to give very active remedies, 
such, for instance, as the alkaloids, in small doses frequently repeated. 
When the dose for an infant or child is to be fixed in relation to the dose 
for an adult, the calculation should be made in proportion to the quantity 
to be taken daily. Thus, if the quantity which an adult should take be 5 
grains three times a day, and if the dose for an infant of one year be as- 
sumed to be a tenth of the adult dose, then the quantity to be taken by 
the infant during the twenty- four hours should be if = IJ grains in di- 
vided doses during the twenty-four hours. 

Various scales and formulae have been suggested for calculating the 
dose for age. The following scale is perhaps as good as can be devised : — 

First month jV of the dose for an adult. 

1 year j\ '' 

2 years i " 

3 years I *' 
5 years i " 
10 years | " 
14 years the same dose as for an adult. 

A more accurate method would be to base the proportions on the rela- 
tive weights, but this is not practically convenient. Bolognini has sug- 
gested the following formula, which is based on the ratio of the average 
weight at various ages to the average adult w^eight : — 

where d = dose, and a = years of age. For infants under one year the 
formula is : — 

"^"=20 — m 
m = number of months. 

These scales and formulae are of use as affording general indications, 
but there are many exceptions. On the whole, the tendency from their 
use would be to give rather too high doses of alkaloids, especially opium 
and its derivatives, and too small doses of laxatives and antiseptics. 

The following notes may be of service, but the doses mentioned may 
often be exceeded. 

DAILY DOSES. 

Alcohol (brandy). — At 1 year, 5j to 5ij ; at 3 years, 5vj to 5j (daily). 
Antipyrin. — At 1 year, gr. ij to iij ; at 3 years, gr. vj to viij (daily). 



526 



II 



PRESCEIPTIOyS AXD RECIPES. 527 

Belladonna. — Large doses are well borne, and must be given if tlio 
physiological eflect is desired. Of the extract, gr. J for an infant ; for a 
child of 5 years, gr. \ (thrice a day). 

Bismuth, — Rather large doses are necessary in intestinal disorders. Of 
the subnitrate gr. xv for an infant aged 1 year, and about twice this quan- 
tity for a child of 5 years. 

Bromides. — Potassium bromide, at 3 months, gr. jss to ij ; at 6 months, 
gr. iij to iv : from 1 to 3 years, gr. v to x ; from 3 to 5 years^ gr. x to 
XV. Of ammonium bromides doses half as large ag-ain may be given. 
When bromides are really required, larger doses should be given without 
hesitation until the desired etiect is produced, but the dose must be in- 
creased gradually, and stopped as soon as possible. 

Calomel. — As a purgative in a single dose (^not suitable for infants under 
6 months as a rule) : under 1 year, gr. | to j ; at 2 years, j to iij. The 
purgative etlect of calomel differs very much in different individuals, as a 
rule it acts more readily in those disposed to be fat. As an antiseptic, 
under 1 yeargr. ^V to yV every two or three hours to 5 or (> doses. Above 
this age the doses may be doubled and the course continued rather longer. 

Chloral. — Under 6 months, gr. j ; at 1 year, gr. iij ; at 2 years, gr. viij ; 
at 5 years, gr. xv (daily doses). 

Opium. — Tincture : under 1 year, ny to ij in divided doses. It is not 
an hypnotic suitable for infants and young children, but is valuable in 
minute doses as an intestinal sedative. 

Quinine. — Well borne a.'^a rule. Of the sulphate or hydrochU)rategr. ij 
to iij for an infant, of the tannate gr. iv to vj. 

Potassium ehlorate. — At 1 year, gr. jss : at 2 years, gr. iij to vj. 

Potassium iodide. — At 1 year, gr. ij to iij ; at 2 years, gr. iij to vj ; at 5 
years, gr. x (daily). 

Sodium salicylate. — At 1 year, gr. iv to v ; at 3 years, gr. vj to ix ; at 5 
years, gr. xij to xv. To be given in divided doses everj^ 3 or 4 hours for 
thirty-six to forty-eight hours, except under special circumstances, when 
the effect should be watched. 

PRESCRIPTIONS AND RECIPES. 

The following prescriptions and applications are referred to in the text, 
but it has been thought more convenient to bring them together here : 

Simple Linctus — 

(a) Acid : Tr. Camph. Co. "i^ij-iv. 

Acid. Hydrochlor. Dil. ny. 

Vin. Ipecac. T\"J-v. 

Glycerin. tt\^x. 

Aq. Caru. ad 3j. 

(6) Alkaline : Vin. Ipecac. "I'U-^'J- 

Pot. Bicarb. gr. iij 

Aq. A net hi ,~j 

Morphine Linctus — 

Liq. Morph. Hydrochlor. tt|^)-'U- 

Acid. Hydrochlor. Dil. Ti\J. 

Tinrt. Aurantii Rec. n\^xx. 

Glycerin. "l,x. 

Aq. ad ."J. 

For children over 8 years. 



528 



APPENDIX. 



Apomorphine Linctus — 

Apomorphin. Hydrochlor. 
Acid. Hydrochlor. Dil. 
Syrupi Limon. 
Aq. 
For children over 8 years. 

Bromoform Linctus (Whooping-cough)- 

Bromoform. 
01. Amyg. 
Mucil. Tragacant. 
Aq. Caru. 

Local Applications for the Mouth — 

(a) Pot. Permang. 
Aq. 

(b) Cupr. Sulph. 
Aq. 

(c) Kesorcin. 
Aq. 

(d) Sodii Salicyl. 
Cocain. Hydrochlor. 
Aq. 

Mouth Washes — 

(a) Thymol. 
Boracis 
Spir. Rect. 
Aq. Dest. 

{b) Thymol. 

Sodii Benzoat. 
Tr. Eucalypt. 
Aq. Dest. 
Boric Acid Cream. 



gr. ^V- 
nij. 

ad3j. 



nix. 

TT^XV. 

ad3j 



gr. ij-iv. 

gr. xxiv. 

gr. iv-viij, 

gr. V. 
gr. viij. 



gr. V). 

3ss. 

5ij. 
adOj. 

gr. iij. 
3iv. 

3ij. 
ad Oj. 



Loffler^s Solution — 

Menthol 
Toluol 
Creolin 
Alcohol 

Gaucher'' s Solution- 



DIPHTHERIA. 



10 parts by weight. 
36 parts by measure. 
2 parts by measure, 
to 100 parts by measure. 



Camphor 

Carbolic Acid (crystals) 

Tartaric Acid 

Castor Oil 

Alcohol (90°) 



20 parts. 

5 '' 

1 '' 

15 '' 

10 '' 



Dissolve the carbolic acid in the alcohol, add the camphor, then the tar- 
taric acid, and lastly the castor oil. 



PRESCRIPTIOXS AXD BECIPES. 629 



CREASOTE. 




Creasoti 


ni^ss. 


Spirit. Reot. 
Spirit. Chlorof. 
Tinct. Card. Co. 


a a ni^ijss. 


Extract. Glycyrrh. Liq. 


aa n\^v. 


Mucil. Tragacanth. 
Aq. 


ad oj. 


>se at 1 year. 





» 



HEART FAILURE. 

Elixir Camphorn' plartiiuiale & Westcott) — 

Spirit of Camphor ')X. 

Syiup .")V. 

Distilled Water 3j. 
Contains camphor gr. iv in 3j. 

Hypodermic Injection of Caffeine — 

In water 3J, dissolve sodium salicylate gr. xvj. or sodium benzoate gr. 
XX. and add caffeine gr. xx. Sterilize by boiling for 15 minutes. Gr. j in 
TTliij. 

RHEUMATISM. 

Sodii Salicylatis oj-o- 

Tr. Aurantii Rec. 

Glycerini aa 5U- 

Aq. ad aj. 

Dose — 3j every 2 or 3 hours. 

Sodii Salicylatis 

Sodii Bicarbonatis aa .jj'^s- 

Tr. Aurant. Rec. 

Glycerin. aa 3iij- 

Aq*. ad 5ij. 

Dose — 5U ever^• 3 or 4 hours. 

Sodii Salicyl. 3J-5ij. 

Liq. Ammon. Acet. 

Syrupi Aurant. aa 3"j« 

Aq. ad .\j. 

Do^e — 5j everj' 2 or 3 hours. 

Sodii Bicarbon. gr. xxx-xl. 

Potassii Acetatis gr. x. 

Aq. .■*,H«. 

In efferveircence with citric acid (gr. x) or fresh lemon juice (3J8s) every 
f 4 hours, to be reduced after 24 hours. 

34 



530 APPENDIX. 

Quinine and Alkali (Garrod). 

Quininae Sulph. gr. ij. 

Potassii Bicarb. gr. xx. 

Tr. Aurantii ^xij. 

Mucil. Acac. 5ss. 

Aq. ad 3ij. 

(A single dose.) The quinine is rubbed up with the bicarbonate, dis- 
solved in water, and the mucilage added afterwards. 

Jules Simons' s Liniment — 



Extr. Belladon. 
Olei Hyoscyam. 
Olei Anthemidis 






1 part. 
8 parts. 
15 '' 


Fuller^ s Lotion — 








Carbonate Sodium 
Laudanum 
Glycerine 
Water 






5vj. 

Six. 




PHOSPHORUS. 




Tinctured Phosphori Composita (B. 


P.C.)— 




Phosphorus 
Chloroform 






gr. iij. 

3v. 



Warm gently in a stoppered bottle till dissolved, and add the solution 
to ethylic alcohol 5xv. Shake and keep in the dark (1 in 600). 

Elixir Phosphori (B.P.C.)— 

Tr. Phosphori Co. 5j. 

Glycerin 5iv. 

To be prepared freshly : contains gr. ^V in 3J. Dose for an infant, 

TT^X-XX. 

Oleum Morrhuse Phosphoratum — 

01. Phosphorati (B.P.) 5ij ttlxI. 

01. Morrhuse Oj. 

Contains x^o iii 5j> which is the dose. 



LOCAL APPLICATIONS. 

Lotio Calaminse — 

Calamin. Prseparat. gr. xl. 

Zinci Ox. gr. xx. 

Glycerin. 9j. 

Aq. ad ^j. 



I 



FOODS AXD BEVERAGES. 531 

Loiio Hydrargyri c. Acido Carbolico (Shadwell)— 

Liq. Hydrarg. Perchlor. n^^xx. 

Acidi Aeetici Dil. inx\. 

01. Terebintbiiiie "^ij 

Sol. Ac. Carbol. (1 in 40) ad '^.* 

Liq. Chlori — 

Potassii Chloratis ^iij. 

Acid. Hydrochlor. (fort.) 3j. 

M- * ad OJ. 

Add the acid to the chlorate in a large bottle : when thecliloriue given 
off has displaced the air add the water gradually, corking and shaking the 
bottle after each addition. (Should be made as required.) 

Spirit of Soft Soap— 

(Spiritus Saponis Kalini.) 

Half a pound of soft soap is mixed thoroughly with 4 11. oz. of rectified 
spirit, strained through muslin, and scented with oil of lavender (5 drops). 

Ung. Chrysarobin. Co. (Unra) — 

Chrysobine 5 parts. 

Salicylic Acid 2 *' 

Ichthyol 5 " 

Simple Ointment 100 " 

Dusting Poicder — 

Zinc Oxide, Boric Acid, Starch powder, equal parts. 

Antiseptic Dusting Powder — 

Zinc Oxide, Boric Acid, Starch powder, Mercurj- Subchloride, equal 
parts. 



FOODS AND BEVERAGES. 

Cream Mixture — (Meigs modified by Rotch). — Cream (about 15 per 
cent.), 2 parts ; milk, 1 part : lime water, diluted with ^ water, 2 parts ; 
solution of milk-sugar (33 drachms, water 3 fl. oz.) 3 parts. Or cream (20 
percent.), ojss : milk, 3j ; water, 3v ; milk-sugar solution as above, 
3iijss. 

Egg JJ'ater. — The white of an egg stirred into 4 to 6 11. oz. of boiled 
water, and sweetened with white sugar or a solution of milk-sugar. 

Whey. — After the milk has been curdled with rennet, the curd shouM be 
beaten up with a fork and the whey strained off through muslin. Whifr 
Wine Whey is made by adding 2 fl. oz. of sherry to half a pint of milk 
just at the boiling point. The mixture is then boiled for two minutes, and 
afterwards allowed to cool in a basin. The whey may be poured oil', or 
strained off as directed above. 



532 APPENDIX, 

Raw Meat Juice. — Mince fine \ lb. best rump-steak, free from fat and 
gristle, add two tablespoonfuls of water, stir, and set aside for one hour. 
The juice is expressed through muslin by twisting. From 2 to 3 fl. oz. may 
be given in twenty-four hours. It may be given in milk, the taste of which 
it does not much modify. (Cheadle.) 

Raw Meat Pulp. — Take 2oz. of best rump-steak, scrape fine with a knife 
on a cook's board, removing all gristle and fat. If not quite pulped, 
pound in a mortar. May be taken alone, mixed with a little finely-minced 
parsley (about half a teaspoonfal), or spread between thin slices of bread. 
At 1 year this quantity may be given during the day. 

Fresh Lemonade. — Rub two or three lumps of white sugar on the clean 
rind of a lemon, squeeze out the juice, and remove pips and shreds ; place 
together in a jug with a bottle of soda-water or an equal quantity of 
boiled (cold) water. 

Imperial Drink — 

Cream of Tartar gss. 
1 Lemon cut in slices 

White sugar J lb. 

Water Oiij. 

Mix together and let them stand for half an hour. 



BATHS. 

Warm Bath and Pack. — The bath should be large in proportion to the 
size of the child, and a large quantity of water (at first at the temperature 
of 95° F.) should be used. During the bath, which should last 20 minutes, 
the temperature of the water should be raised to 104° F. or 105° F. by 
the careful addition of hot water. The child should be kept immersed up 
to the neck, and a blanket should be thrown loosely over the bath, and 
held round the neck. Meanwhile, a bed is to be prepared thus : — Turn 
down the bed-clothes, and put a blanket on the bed, so that it projects a 
little over the foot. Immediately before the child is to be taken out of the 
bath, a fairly thick sheet, thoroughly wrung out of hot water, is placed 
over the blanket. The patient is now lifted out of the bath, and laid on 
the sheet, in which it is tightly wrapped up, with the arms inside ; the 
part of the sheet which projects beyond the feet is folded and tucked 
firmly under the feet. In adjusting the sheet, care must be taken to avoid 
creases, and to tuck it in firmly round the neck. The blanket is now 
folded round the patient, great care being taken to avoid any looseness or 
irregularity by which air could enter. The bed-clothes are now pulled 
down, and tucked in firmly at the foot, sides, and neck, so as to exclude 
the air. Profuse perspiration commonly begins in a short time. The 
patient should remain in the pack about an hour. The pack is then un- 
done, and the patient quickly rubbed down with a warm, rough towel, 
put into a second bed (which has been well warmed), if such be available, 
and covered with plenty of light, warm bed-clothing. The shift from the 
pack to the bed must be done as rapidly as possible. In mild weather the 
window may be open while the patient is in the pack, but draughts should 
be avoided. (Jiirgensen.) 






BATHS. 633 

Bran Bath. — Take 2 oz. bran for each gallon of water, enclose it loosely 
in a muslin bag, and allow it to soak for 10 minutes ; stir the water with 
the bag, and remove. 

Starch Bath. — Potato starch, ^ oz. to each gallon of water. 

Linseed Bath. — Linseed meal, h oz. to each gallon of water. 

Alkaline Bath. — Sodium Bicarbonate, J^ oz. to each gallon of water. 
About 1 drachm of borax for each gallon may be added with advantage in 
many cases. 

Mustard Bath.— ^histard, 1 oz. to each gallon of water (at 98" to 106° F.). 



I 



I 



INDEX. 



4BSCESS, of brain, 473 
j\ j>erinephritio, 4^-50 

retropharynjioal. ol() 
Acute specific disoas«.>s, 8;> 

adynamia in, 9'2 
complications ami sequela', 

80 
incubation i>erii>ds, 84 
mental disorders after, Sti 
mortality from, 83 
nervous dis<^nlers after, 87 
prophylaxis of. 84 
treatment of, 88 
alcohol, 90 
antipvretics, 90, 92 
feediuir, 89 
hydrotiierapy, 90, 91 
nursintr, 88 
Adenitis, tulx^rculous, 173 
Adenoid vegetations, 305 

chest deformities produced bv, 

309 
symj)tonis, 306 
treatment, 308 
Ages of childluK>d, 17 
Alalia idiopathica, 436 
Albuminuria, 417. 418, 419 

of puberty, 417 
Alopecia areata, o21 
Amyotrophy, 494 
Ansemia, 227, 247 
chlorotic, 2oO 
progressive pernicious, 250 
j>seudoleuch{emic, 251 
•iecondarA', 249 
>plenic, 251 
Angeio-neurf»ses, cutaneous, 504 
Anus, ini|xrrforate, 395 

prolapse of, 393 
Aortic incompetence, 282 

stenosis, 282 
Aphthw, Bednar's, 286 
Aphthous slomatiti-s 293; see nUo Mem- 
branous stfimatitis. 
Appendicular TX'ritonitis, 350 
Aj»f>endix, inflammation of, 350 
Appetite, hysterical |)erversion of, 441 
Anthmomania, 45^) 
Arthritis, chronic rheumatic, 218 
deff»rmans, 219 
diphtherial, 222 



Arthritis, gonorrhu-al, 222 

infective, 221 

scarlatinal, 222 
Ascaris lumbric(»ides, 402 
Asphyxia neonatorum, 36 
Asthma, bronchial, 345 

thymic, 269 
Ataxy.' diphtherial, 140 

hereilitarv, 487 
cerebellar, 488 
Athetosis, 486 
Athrepsia, 387 
Atrophy, infantile, 387 

muscular, 494, 498 



BARCCX'K'S centrifugal machine, 62 
baths in health, 2.5 
in fever, 90 
IVdnar'saphthrt\ 286 
Birth palsies, 491 
Blood, normal, 247 

count, 247 
Bothri(K?ephalus latus, 400 
Bottles, feeding, 67 
FJowel, luemorrhage from, in the new 

bom, 51 
Breast-milk, 58 

management of, 59 
feeding, 60 
Bronchiectasis, 342 
causes, 342 
diagnosis, 344 
]>hysical signs, 343 
symjitoms, 344 
treatment, .'i45 
Bronchitis, acute, 314 

bacteri«»logy, 314 
pathology, 315 
prognosis, 317 
symptoms, 316 
trtatmcnt, 318 
chronic, 340 

diagnosis, 341 
progn<»sis, 342 
treatment, 341 
Broncho-pneumonia, 314 
pathoh.gy, 315 
prognos^^ 318 
symptoms, 317 
i treatment, 320 



536 



INDEX. 



CALCULUS, renal, 427 
Cancrum oris ; see Noma. 
Cari)o-pedal contractions ; see Tetany. 
Cephalhaematoma, 36 
Cerebral sinuses, thrombosis of, 476 
Cerebro-spinal meningitis, epidemic, 124 
Cervical glands, tuberculosis of, 168 

rheumatism, 213 
Chest, deformities of, 309 
Chicken-pox ; see Varicella. 
Chilblain, 511 
Childhood, ages of, 17 

mortality of, 21 
Chlorosis, 174, 250 
Cholera infantum, 375 

etiology, 372 

morbid anatomy, 375 

symptoms, 375 

treatment, 380 
Chorea, 225 

duration, 230 

etiology, 225 

heart in, 228 

pathology, 227 

treatment, 230 
Chorea, congenital spastic, 486 

'^ electric," 450 ; see also Hysterical 
delirium. 
Choroiditis, syphilitic, 202 
Clinical examination of infants, 27 
in laryngeal disease, 29 
in respiratory disorders, 30 
Clothing, 24 
Colic, renal, 427 
Colitis ; see Gastro-enteritis. 
Colles' law, 191 
Colon, catarrh of, 384 

dilatation of, 385 
Constipation, 389 

alimentary, 390 

anatomical, 391 

symptomatic, 390 

in nursing women, 64 

treatment, 392 
Contractions, carpo-pedal ; see Tetany. 
Contracture, hysterical, 441 
Convulsions, infantile, 451 
Coprolalia, 450 
Coryza in infants, 196, 203 
Cretinism, 255 

diagnosis, 258 

treatment, 261 
Croup, 298 

congenital, 311 

spasmodic, 298 

DEAF-MUTISM, 437 
Deafness, 436 

syphilitic, 202 
Degeneration, reaction of, 490 
Delirium, 83 
febrile, 86 



Delirium, hysterical, 440; see also Night- 
terrors. 
Dentition, 285 
first, 286 

symptoms attributed to, 287 
treatment, 287 
second, 286 
Dermatitis, 517 
catarrhal, 518 
pyococcal, 517 
Desquamation of tongue, 289 
Diarrhoea, 365 

acute summer, 372 
etiology, 372 
symptoms, 372 
treatment, 377 

chronic ; see Gastro-enteritis, chronic, 
lienteric, 384 
Diphtheria, 132-151 

broncho-pneumonia, 137 
conjunctival, 138 
diagnosis, 140 
heart, failure of, 134, 137 
immunization in, 151 
laryngeal, 136 
mixed infection, 134 
paralysis, 138 
ataxic, 140 

cardio-respiratory, 140 
generalized, 138 
of palate, 139 
of pharynx, 139 
prognosis, 140 
treatment, 148 
pharyngeal, 134 
prognosis, 142 
of skin, 138 
toxaemia, 137 
treatment, 132 

antitoxic serum, 142 
results of, 143 

influence of complications, 145 
general, 148 
local, 149 
Dirt-eating ; see Pica. 
Duodenum, congenital narrowing of, 395 
Dyspepsia, 367, 369 
Dystrophies, primary muscular, 499 

EAE-DISEASE, syphilitic, 202 
Earth-eating ; see Pica. 
Echolalia, 450 
Eclampsia, 451 

nutans, 449 

renal, 421 
Eczema, 525 

seborrhoeic, 522 
Emphysema, chronic pulmonary, 340 
Empyema, 332 

bacteriology, 338 

diagnosis of, 335, 338 

loculated, 337 



IXDEX. 



537 



Endocarditis, acute simple, *277 

chronic, 279 

malignant. 277 

diagnt^sis, 27S 

symptoms, 278 

morbid anatomy, 277 
Enteric fever ; stv Typhoid. 
Enteritis, catarrhal. 3ti7 

tuberculous, 173 
Epilepsy, -^'yS 

etiology. 4o4 

focal : stT Jacksonian, 4.5G 

hystero, 4oo 

treatment. 4o7 
Epiphysitis, syphilitic, 201 
Epithelial pearls, 285 
Eruptions, syphilitic, 192, 194 
Erysii>elas neonatorum, 42 
Erythema, 508 

fugax, 508 

intertrigo, 508 

multiforme, 510 

neonatorum, 44 

nodosum, 211 

perni«\ 511 

scjirlatiniforme, 509 

simplex, 508 

syphilitic, 194 

F.ECES, bacteria of, 69 
character of, in infancy, 55 
Facial irritability, 445 

paralysis, 491 
Fatty degeneration, acute, of the new- 

l3om, 40 
Feeding, artificial, 65, 73, 74, 75 

ass's milk, 65 

condensed milk, 66 

cow's milk, 65 

cream mixtures, 65, 66 

"fat milk," 66 

in second year, 81 
Feeding bottles, 67 
Fever, general remarks on, 34 

glandular, 123 
Focal epilepsy, 456 
Foot-and-mouth disease ; see Aphthous 

stomatitis. 
Friedreich's dlsea'^e, 487 
Funmcle, 519 

syphilitic, 196 

G.\STRO-EXTERITIS, acute, 369 
complications, 376 

treatment, 377 
Gastro-enteritis, chronic, 383 

morbid anatomy, 384 

projrnosis, 385 

symptoms, 383, 384 

treatment, 385 
Ga.«ttro-inte8tinal diseases, acute, 365 

bacteriology, 373 



Gastro-inte.stinal diseasi^s. catarrh. 369 

cholera infantum, 375 

diarrha*a, acute summer, 372 

dysjH'psia, 367, 3()9 

enteritis, catarrhal, 3(»7 
Genito-urinary system, diseases of, 411 
Gcographieal tongue, 289 
Cierman measles; ,*>• Kubella. 
Glandular fever, 123 
Gliomata, intnieranial, 478 
Glossitis, syphilitic, 197 
Goitrts 255 

exophthalmic, 255 
Growth, rates of, 18 

HEAD-IiANGIXG," 449 
ILi'matonia of the sterno-n)astoid, 
38 
HaMuaturia, 418 
HaMuoglobinuria, 418 

acute, of new-born, 41 
Hfemophilia, 51, 253 
Haemorrhage during jKirturition. 37 
gastro-intestinal, 51 
meningeal, 37 
Hnemorrhagic disease of the new-born, 51 
Hay fever, 346 
Head, retraction of, 33 
Headache, 434 

from refractive errors, 434 
in cerel)r;il abscess, 474 
in otitis, 435 
toxic, 434 
Heart, congenital affections of, 270 
diseases of, 270-2S4 
normal, 270 
Heberden's nodes, 219 
Height at various ages, 20 
Hemiplegia, 481 
aopiired, 482 
congenital, 482 
secondary, 481 
Hepatitis, suppurative, 364 
Herpes, 514 
Holt's apparatus for breast -milk analvsis, 

61 
Hodgkin's disea.se, 252 
Hvdatid disease, 40(> 
eti(.logy, 406 

gcfjgraphical distribution. 4^(7 
intracninial, 409 
r.f kidnev, 410 
of liver, *407 
of lung, 4(»8 
of sjdeen, 410 
Hvdrocephaloid condition, 388 
HydrcKxphalus, 199, 469 
acute, 461 
chronic external, 469 

internal, 470 
pathf)logy, 470 
symptoms, 471 



538 



INDEX. 



Hydrocephalus, treatment, 472 
Hydronephrosis, 428 
Hyperpyrexia, rlieumatic, 211 
Hysteria, 440 

appetite, perversion of, 441 

contracture, 441 

delirium, 440 

joints, affections of, 441 

paralysis, 441 

somnambulism, 440 

treatment, 442 
Hystero-epilepsy, 455 

1CTEEUS neonatorum, 38 
Impetigo, 517 
Incubation, periods of, 84 
Infancy, age of, 17 
Infantile paralysis, 494 
symptoms, 495 
treatment, 496 
Influenza, 112 

complications, 113 
treatment, 115 
types, 112 
Intestinal obstruction, 395 
acquired, 395 
congenital, 395 
diagnosis, 397 
symptoms, 395 
treatment, 397 
Intestines, length of, 52 

tuberculosis of, 178 ; see also Gastro- 
intestinal diseases, 
tuberculous infection through, 158 
Intracranial tumour, 477 
Intussusception, 395, 397 
Itching, 514 

JACKSONIAN epilepsy, 456 
Jaundice, catarrhal, 357 
infective, 359 
Joints, hysterical affections of, 441 

KEKATITIS, svphilitic, 202 
Kerion, 520 
Kidneys, diseases of, 419 
abscess, 430 

amyloid degeneration, 425 
bacteriology, 420 
calculus, 427 
cystic (congenital), 426 
eclampsia in, 421 
hydronephrosis, 428 
nephritis, 419 
pyelitis, 429 
renal colic, 427 
tuberculosis, 431 
tumours, 430 

LACTATION, prolonged, 57 
Laryngeal catarrh, chronic, 298 
stridor, congenital, 311 



Laryngismus stridulus, 312 ; see also 

Tetany. 
Laryngitis, acute, 297 

catarrhal, 298 

chronic, 298 

treatment, 299 
Larynx, diseases of, 298 

papilloma of, 299 
Leuchsemia, 252 
Leucocytes, 247 
Lichen, 525 

urticatus, 505, 525 
Lienteric diarrhoea, 384 
Liver, diseases of, 356 

acute yellow atrophy of, 360 

amyloid degeneration of, 363 

cirrhosis of, 361 

fatty degeneration of, 364 

fatty infiltration of, 363 

jaundice, 356 

catarrhal, 357 

infective, 359 

suppuration of, 364 

tuberculosis of, 181 
Lumbar puncture, 126 

MALAKIAL fever, 152 
aestivo-autumnal, 152 

cachexia, 153 

hsematozoon, 153, 154 

in America, 155 

pernicious, 153 

prognosis, 154 

quotidian, 153 

treatment, 154 
Mamma, inflammation of ; see Mastitis. 
"Manie de pourquoi," 450 

de toucher, 450 
Marasmus, 387 

syphilitic, 193 
Mastitis, 41 
Materna, 75, 78 
Measles, 100 

complications, 102 

diagnosis, 102, 107 

enanthem, 101 

German ; see Eubella. 

prognosis, 103 

symptoms, 101 

treatment, 103 
Meconium, retention of, 390 
Mediastinal glands, tuberculosis of, 169 
Megrim, 435 
Melsena neonatorum, 50 
Meningeal haemorrhage, 37 
Meningitis, 459 

bacteriology, 464 

basal (posterior), 466 

diagnosis, 463 

epidemic cerebro-spinal, 124 

etiology, 459 

pathology, 461 



I 



IXDEX. 



539 



Meningitis, patliology, pi>storior basal, 406 
prophylaxis, 460 
secondary to pneinnonin, ?>2C> 
symptoms, 4(U 
tuberculous, 400 
treatment, 465 
Mental disorders, after infect ituis dis- 
eases, 86 
Migraine, 43-5 
Miliaria, 52o 
Milk, condensed, 00 

cow's ; .*er Artificial feetling. 
and human, 73 
modification of, 74, 75, 386 
drieil, 07 
digestion of, 54 
disease disseminated by, 68 
efTect of boiling, 68 
human, 52 

analysis of, 59, 61, 73 
composition of, 53, 54, 58, 59 
quantity of, 55 
laboratories, 73 ! 

methoils of sterilizing, 69, 70 j 

microbes in, 68 
pasteurization of, 72 
secretion of, in infancy, 41 
sterilized, 69 

advantages and drawbacks, 71, 
72 
tuberculous infection by, 156, 158 
Mitral incompetence, 279 

stenosis, 280 
Morbus Cfendeu.*, 272 
Mortality of childhood, chief causes, 21 

from acute specific diseases, 83 j 
Mucous tubercles, 197 
Mumps, 121 

diagnosis, 122 
orchitis, 122 
pathology, 122 
symptoms, 121 
treatment, 12^5 

VASO-PHARYNGEAL obstructions, 
^> 309 

deformities of chest from, 309 

-pharj-nx, adenoid vegetations of, 305 
Navel, diseases of, 44 

htemorrhage, 46 

phlegmonous inflammation, 44 

ulceration, 44 
Nephritis, diffuse, 419 

chrrmic, 422 

glomemlo, 420 

scarlatinal, 108, 420 
Nerves, lesions of, 4H9 
Nervous dL^^jrders after infectious diseaaes, 
87 

system in infancy and childhood, 432 
Neuritis, multiple, 492 
Night terrors, 312, 433 



Nodding sixism, 448 
Nodules, rlieumatic, 210 
Noma, 295 
Nystagmus, 448 

/T?DEMA neonatorum, 49 

vPj Omphalitis; .»«r Navel, diseases of. 

Ophthalmoplegia, diphtherial, 139 

Orchitis iu mumps, 122 

Otitis, 302 

diau'uosis. 302, 4(U, 473 

etiology, 114, 302 

symptoms, 3()2 

treatment, 303 
Oxyuris vermicularis, 404 

PADDLIN(;, risks of, 26 
Palate, syphilis of, 203 
tuberculosis of, 181 
Paralvsis, facial. 4i»l 
hysterical. 441 
infantile, 494 
Paralysis, pseudo-hypertrophic, 500 
Parasites, intestinal, 399 
Parotitis ; w Mumps. 
Parturition, hjcmorrhagic extravasations 

during, 3() 
Pasteurization of milk, 72 
Pavor nocturnis, 433 
Pediculi capitis, 515 
Peliosis rheumatica, 510 
Pemphigus, 513 
neonatorum, 51 
syphilitic, 192 
Pericarditis, 272 
causes, 272 
symptoms, 273 
treatment, 270 
Pericardium, adherent, 275 
etlusion into, 273, 274 
inflammation of, 272 
Perinephritic abscess, 430 
Periostitis, syphilitic, 2(>0 
Peritoneum, acute miliary tuberculosis of, 
174 
chronic, 175 
Peritonitis, acute, 347 

dia^Miosis. 348, .353 
niorltid anatomy, 347 
symptoms, 347 
treatment, 348, 354 
appendicular, 350 

hK\nl adhesive, 351 
general, .'^53 
suppurative, 352 
chronic, 348 

symptoms, 349 
treatment, 349 
Perityphlitic aljscess, '.Vt2 
Peritvphlitis ; *[•« ApiHMnlicular |>erito- 

nitig. 
Perleche, 204 



540 



INDEX. 



Pernicious anaemia, 250 
Pertussis ; .see Wliooping-cough. 
Pharynx, diseases of, 300 

abscess, 301 

behind, 310 

gangrene, 301 ; see also Adenoid 
vegetations. 
Pharyngitis, 297 

acute, 300 

treatment, 303 

chronic, 304 

diagnosis, 301 

granular, 304 

treatment, 308 
Phthisis, chronic, 186 
Pica, 442 
''Pink-eye," 105 
Pleurisy, 332 

bacteriology, 334 

loculated, 337 

purulent, 332 

rheumatic, 210 

sero-fibrinous, 332 

symptoms, 334 

treatment, 338 
Pleuro-pericarditis, 276 

-pneumonia, 330, 335 
Pneumococcus, the, 323 
Pneumonia, acute lobar or fibrinous, 322 

bacteriology, 323 

complications, 326 

diagnosis, 326 

etiology, 322 

physical signs, 325 

symptoms, 324 

treatment, 331 

meningitis, secondary to, 326 
Poliomyelitis, acute anterior, 494 
Prolapsus ani, 393 
Prurigo, 507 
Pruritus, 514 
Pseudo-hypertrophic muscular paralysis, 

500 
Pseudo-paralysis, syphilitic, 201 
Psoriasis, 525 

Pulmonary tuberculosis, 183 
Pulse, normal, 32 
Pulsus paradoxus, 274 
Purpura, 510 
Pyelitis, 429 

Pylorus, congenital stenosis of, 389 
Pyuria, 418 

RAYNAUD'S disease, 606 
Kectum, catarrh of, 384 
prolapse of, 393 
Regurgitation of milk, 55 
Renal colic, 427 
Respiratory passages, diseases of the 

upper, 297 
Respiratory spasm, 311 
congenital, 311 



Retraction of head, 33, 467 
Retro-pharyngeal abscess, 310 
Rhagades, syphilitic, 197 
Rheumatic acute arthritis ; see Rheumatic 
fever. 

cachexia, 218 

chronic ; see Rheumatoid arthri- 
tis. 

podules, 219 

fever, 208 

diagnosis, 212 

erythema, 211 

endocarditis, 209, 213 

hyperpyrexia, 212 

pericarditis, 209 

rashes, 211 

subcutaneous nodules, 210 

symptoms, 209, 211 

tonsillitis, 210 

treatment, 214 
Rheumatism, acute ; see Rheumatic fever. 

cervical, 213 

chronic, 218 

muscular, 210 
Rheumatoid arthritis, 219 
Rhinitis, 297 

diphtherial, 297 

simple, 297 

syphilitic, 297 
Rickets, 232 

cranio-tabes, 235 

diagnosis, 240 

deformities, 236 

dentition, 236 

etiology, 232 

pathology, 233 

symptoms, 311 

treatment, 241 ; see also Scurvy. 
Rigidity, paraplegic, 486 

spastic, 484 
Ringworm, 519 
Roseola, 105 
''Rose rash," 105 
Rotheln ; see Rubella. 
Rubella, 103 

aberrant types, 105 

diagnosis, 106, 107 

enanthem, 104 

incubation, 103 

morbilliform, 104 

scarlatiniform, 104 

symptoms, 104 

treatment, 105 



QACCHAROMYCES 

U Thrush. 

Saliva in infancy, 285 

Scabies, 515 

Scarlet fever, 106 
adenitis, 108 
arthritis, 109 
bacteriology. 111 



albicans ; see 



INDEX. 



54L 



Scarlet fever, a>mplications, 108 

diagnosis, 107, 109 

ini'ubation, UXi 

laryniritis in, 110 

mortality from, 83 

nephritis in, 108 

otitis in, 108 

pharvnsjitis, 108 

symptoms, 106 

temperature, 108 

treatment, 110 
Sclerema neonatorum, 48 
Scrofula ami tubercle, 173 
Scurvv, 242 

etiolo^'y, 243 

morbid anatomy, 243 

prophylaxis, 24G 

symptoms, 244 

treatment, 245 
■ ■ Scurvv-Kickets " ; !<€e Seurvv. 
Sea-air,' 26 
Seborrh«va, 522 
Seborrhcpie eczema, 522 
Sex, influence on mortality, 22 
■-^rmoid flexure, .'^^ 

abnormal coiling of, 391 

catarrh of, 384 
^ !ius-throml>osis, cerebral, 476 
>Kull, natif(.rm, 200 
Sleep in infancy and childhmMl, 23 
•^niall-pox, 94 

complications, 98 

incunation, 96 

modified, 98 

symptoms, 96 

treatment, 98 

vaccination, 94 
<nuftles," 196 
^ iiinambulism, 440 
""j.a.xms, 444 

habit, 449 

laryngeal, 311 

loGil, 448 

respiratory, 311 

saltatory, 450 
^ ;ismuH nutans, 449 
^ :istic rigidity, 484 

varieties, 484 
>l>eech, defect** of, 4.'i5, 450 
Spleen, tul»erculo>is of, 181 
Splenic ana-mia, 251 
Stammering, 435 
Sterilization of milk, 69 
Sterilisers (milk), 70 

Aymarrl's, 70 

Cat heart's 70 

Sf)xh let's, 71 
Stemri-ma^toid, hjematoma of, 38 
Stomach, dilatatif»n of, .'i83 ; »ee also Ga»- 
tro-intestinal dis^»nler8. 

size and jKMition of, 52 
oniatitis, 289 



Stomatitis, aphthous, 293 

catarrhal, 289 

erythematous ; sec C atarrhal. 

gangrenous (noma), 295 

herpetic; s«-f Ulcerative. 

meujbninous, 291 

thrush, 294 

uUenitive, 291 
Stuttering, 435 

Stridor, eongenital laryngeal, 311 
" Su<'king pads," 285 
Suckling, duration of, 56 

fre<|Ueney of, 56 
Sudani ina, 525 
Synovitis, rheumatic, 209 

syphilitic, 201 ; sec <tli<n Arthritis. 
Syphilis, ae<iuire<l, 204 

treatment, 205 

inheritetl, 191 

age, 192 

iione lesions, 200 

CoUes' law, 191 

contagiousness, 202 

coryza, 196 

diagnosis, 203 

epiphysitis, 201 

erythema, 194 

furuncle, 196 

Kl(»s>itis, 197 

intestinal, 198 

late, 202 

liver, 198 

lymphatic glan«ls, 198 

marasmus, 193 

mucous tubercles, 197 

nervous system, 198 

papular eruption, 195 

jtapuhi-Mjuamous eruption, 19"> 

pcrniihigns, 192 

periostitis, 200 

f>seu<lo-paralysis, 201 

prognosis, 204 

rhaKades, 197 

"snuflles," 196 

spleen, 198 

treatment, 205 

TAHKS mesenterica, 158 
"Taches cerebniles," 462 
Tape-worm, 4(J0 
Ta-nia, .399 

canina, 400 

echinococcus, 407 

medifK-;incllata, 399, 400 

nana, 40] 

solium, 399 
Temiieniture, subnormal, 36 
Teeth, carious, 2KH 

eruption of ; /v< I>entition, 286 

in congenital syphilis, 202 
Tenesmus, 384 
TetanuM neonatorum, 46 
H 



542 



INDEX. 



Tetany, 444 

diagnosis, 447 
etiology, 444 
facial irritability, 445 
laryngeal spasm, 446 
muscular rigidity, 445 
treatment, 447 
Trousseau's sign, 445 
Thorax, 31 
Thrombosis of cerebral sinuses, 476 

umbilical vessels, 45 
Thrush, 294 ; see also Membranous stoma- 
titis and Aphthous stomatitis, 294 
Thymic asthma, 269 
Thymus gland, 255, 267 
Thyroid gland, 255 
Thyroiditis, acute, 255 
Tics, convulsive, 449 
Tinea capitis, 519 
corporis, 520 
Tongue, 181 

desquamation ( geographical tongue ) , 

289 
syphilis of, 197 
tuberculosis of, 181 
Tonsillitis, acute, 300 
diagnosis, 301 
follicular, 300 
gangrenous, 301 
lacunar, 301 
phlegmonous, 301 
rheumatic, 210 
suppurative, 301 
chronic, 308 
chronic, 308 

symptoms, 309 
treatment, 309 
Tonsils and tuberculosis, 308 
Torticollis, rheumatic, 214 
Tricuspid valve, diseases of, 282 
Trousseau's sign, 445 
Tuberculosis, 156-190 
age incidence, 169 
of bones and joints, 167 
etiology, 156 
diathesis, 156 
sources of infection, 156 
general, acute, 164 

chronic, 166 
of intestines, 178 
of kidney, 431 
of liver, ■^181 

of lymphatic glands, 168 
cervical, 168 
mesenteric, 173 
tracheo-bronchial, 169, 173 
of palate, 181 



Tuberculosis, pathology, 159 
peritoneal, 174 
acute, 174 
chronic, 175 
prevalence in childhood, 161 
pulmonary, 183 

broncho-pneumonia, acute tuber- 
culous, 185 
phthisis, chronic, 186 
pneumonia, acute tuberculous, 
184 
sex, 162 
of spleen, 181 
of stomach, 181 
of tongue, 181 
of tonsils, 308 
treatment, 188 
Tuberculin, 187 
Tumor cerebri, 477 
Tumour, intracranial, 477 

symptoms of, 478 
Typhoid fever, 127 
diagnosis, 129 
eruption, 128 
onset, mode of, 128 
serum test in, 130 
treatment, 130 

UMBILICAL vessels, thrombosis of, 45 
Umbilicus ; see Navel. 
Uric acid diathesis, 426 
Urine in infancy and childhood, 411-417 

in nursing women, 62 
Urticaria, 504 
papulosa, 505 
pigmentosa, 508 

VTACCINATION, 94, 96 
V Vaccinia, 94 
Valvular diseases of the heart, 270 

prognosis, 283 

treatment, 283 
Varicella, 99 
Variola ; see Small-pox. 
Varioloid, 98 

WEANING, 56 
Weight at various ages, 20 
rate of increase, 58 
Wet-nurses, 57 
Whooping-cough, 115 
diagnosis, 118 
symptoms, 116 
treatment, 119 
tuberculosis and, 120 

ROSTER, herpes, 514 



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543 pages. Cloth, $3.75; leather, $4.75. 

ON SOME DISORDERS OF THE NERVOUS SYSTEM IN CHILD- 
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WHARTON (HENRY R.). MINOR SURGERY AND BANDAGING. New 

(4th) edition. In one 12mo. volume of 596 pages, with 502 engravings, many of which 
are photographic. Just Ready. Cloth, $3.00, net. 

WHITMAN (ROYAL). ORTHOPEDIC SURGERY. One octavo volume of 
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WHITLA (WILLIAM). DICTIONARY OF TREATMENT, OR THERA- 
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WILLIAMS (DAWSON). MEDICAL DISEASES OF INFANCY AND 
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WILSON (ERASMUS). A SYSTEM OF HUMAN ANATOMY. A new and 

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WINCKEL ON PATHOLOGY AND TREATMENT OF CHILDBED. In one 

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WIPPERN (A. G.) AND BALLENGER (W. L.). A POCKET TEXT-BOOK 
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YEAR-BOOKS OF TREATMENT for 1892, 1893, 1896, and 1897, similar to above. 
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YEO (I. BURNEY). FOOD IN HEALTH AND DISEASE. New (2d) edition. 

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YOUNG (JAMES K.). ORTHOPEDIC SURGERY, In one 8vo volume of 475 
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II 



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